https://orcid.org/0000-0002-6942-6312
In this issue of the journal, Dr Feng and co-workers from Hong Kong aimed to investigate the relative safety of ticagrelor vs. clopidogrel for infection outcomes in patients with cardiovascular diseases. Randomized controlled trials (RCTs) comparing ticagrelor and clopidogrel that reported infection outcomes were included. Ten trials with 37 514 patients in total were included. The authors report that ticagrelor was associated with a lower risk of pneumonia compared with clopidogrel, although the mechanism by which ticagrelor reduces the risk of pneumonia is not known.
Dyspnoea may occur in patients with acute coronary syndrome (ACS) treated with ticagrelor compared with other antiplatelet agents, and is a cause of drug discontinuation.1 Dr Passino and co-workers from Pisa in Italy aimed to explore the contribution of central apnoeas and chemoreflex sensitization to ticagrelor-related dyspnoea in patients with ACS. They found that patients on ticagrelor, as compared with those on prasugrel, more frequently reported severe dyspnoea and showed a higher apnoea–hypopnoea index (AHI) and central apnoea index (CAI) during the day, the night, and the entire 24-h period. In all patients with dyspnoea, the symptoms developed between 24 h and 1 week after ticagrelor administration. The patients on ticagrelor also showed a higher chemosensitivity to hypercapnia. The authors concluded that central apnoeas are a likely mechanism of dyspnoea and should be screened for in patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability and breathlessness in this setting.
The development of atrial fibrillation (AF) during the acute phase of acute myocardial infarction (AMI), also known as de novo AF, occurs during the AMI phase with a prevalence ranging from 2% to 21%.2,De novo AF during AMI has been associated with increased in-hospital mortality and worse overall prognosis.3 Dr Sulzgruber and co-workers from Vienna in Austria aimed to investigate the impact of de novo AF and associated antithrombotic treatment strategies on the patient outcome from a long-term perspective. In a registry study, they found that de novo AF was significantly associated with long-term cardiovascular mortality. While patients with de novo AF were less likely to receive a triple antithrombotic therapy4–6 as compared with patients with pre-existing AF at the time of discharge, this therapeutic approach showed a strong and inverse association with mortality in de novo AF. The authors concluded that de novo AF was independently associated with a poor prognosis, with a 67% increased risk of long-term cardiovascular mortality. Intensified antithrombotic treatment in this high-risk patient population might be considered.
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the cornerstone of therapy in patients with ACS and in those with stable coronary artery disease (CAD) treated with a percutaneous coronary intervention (PCI).1 DAPT reduces the incidence of thrombotic complications but at the same time increases the incidence of bleeding complications that are directly connected with an increase in mortality.7–10 In another study from Italy, Dr Cerrato and co-workers collected the current evidence coming from RCTs on early aspirin interruption after PCI and current drug-eluting stent (DES) implantation, and performed a meta-analysis in order to evaluate the safety and efficacy of this strategy. Four RCTs including a total of 29 089 patients were identified. The authors concluded that after a PCI with current DES, a short DAPT strategy followed by monotherapy with a P2Y12 inhibitor was associated with a lower incidence of clinically relevant bleeding compared with 12 months of DAPT, with no significant differences in terms of 1-year cardiovascular events. This paper is followed by an Editorial by Dr Sulzgruber from Austria.
In a similar project, a Bayesian network meta-analysis was conducted by Dr Khan and co-workers from the USA. The aim was to compare early de-escalation of dual antiplatelet therapy (DAPT) (1–3 months) with monotherapy with either a P2Y12 inhibitor or aspirin vs. 12 months DAPT after PCI with a DES. The authors included seven trials with 35 821 patients and found that there was no significant difference in cardiovascular mortality between 1-month DAPT followed by P2Y12 inhibitor monotherapy, 3 months of DAPT followed by P2Y12 inhibitor monotherapy, or 3 months of DAPT followed by aspirin monotherapy. The authors concluded that early de-escalation of DAPT (1–3 months) to monotherapy with a P2Y12 inhibitor instead of aspirin might be a safer and equally effective approach compared with 12 months of DAPT in patients with PCI and DES. The paper is commented on in an Editorial by Dr Goto from Japan.
Double or triple antithrombotic combination therapy in patients who need anticoagulation and antiplatelet therapy in parallel is debated.11–12 In a study from China, Dr Luo and co-workers investigated the effects of aspirin-omitted dual antithrombotic therapy on myocardial infarction and stent thrombosis in non-valvular atrial fibrillation (NVAF) patients presenting with ACS or undergoing PCI. In a meta-analysis, three trials involving 8845 patients were studied. The incidence of myocardial infarction and stent thrombosis was significantly higher with aspirin-omitted DAT vs. triple treatment, whereas the occurrence of major bleeding was significantly lower with aspirin-omitted DAT vs. triple treatment.
Proprotein convertase subtilisin–kexin type 9 (PCSK9) receptors have emerged as a valid therapeutic target in high-risk patients with whom a sufficient LDL cholesterol reduction is not achieved despite proper use of the maximally tolerated dose of statins.13,14 Dr Montalescot and co-workers have conducted a network meta-analysis investigating the efficacy and safety of alirocumab vs. evolocumab. A total of 30 trials enrolling 59 026 patients were included. Compared with evolocumab, alirocumab was associated with a significant reduction in all-cause death but not in cardiovascular death. The authors concluded that alirocumab and evolocumab share a similar safety profile except for injection site reaction. No significant differences were observed across the efficacy endpoints, except for all-cause death, which may be related to the heterogeneity of the studied populations treated with the two drugs. The paper is accompanied by an Editorial written by Dr Siasos from Greece.
In a Current Opinion paper, Drs Strandberg, Libby, and Kovanen discuss the concept of atherosclerotic cardiovascular disease with a focus on lipid-lowering vs. anti-inflammatory therapy.15 We are also very pleased to publish a consensus document from the Council on Hypertension and Council on Valvular Heart Disease of the European Society of Cardiology, the European Association of Cardiovascular Imaging (EACVI), and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) entitled: ‘Management of patients with combined arterial hypertension and aortic valve stenosis’. In a review paper from Canada, Dr Paquette and co-workers discuss ‘Methodological considerations for investigating oral anticoagulation persistence in atrial fibrillation’.
