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  1. Asia-Pacific ACS Medical Management Working Group, Huo Y, Thompson P, Buddhari W, Ge J, Harding S, et al.
    Int J Cardiol, 2015 Mar 15;183:63-75.
    PMID: 25662044 DOI: 10.1016/j.ijcard.2014.11.195
    Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  2. Zambahari R, Kwok OH, Javier S, Mak KH, Piyamitr S, Tri Ho HQ, et al.
    Int J Clin Pract, 2007 Mar;61(3):473-81.
    PMID: 17313616
    Several therapeutic approaches have been developed to improve the outcome among patients with acute coronary syndrome (ACS). However, treatment with antithrombotic therapies such as oral glycoprotein IIb/IIIa inhibitors has been limited by the lack of efficacy and excess bleeding complications. As the publication of the landmark study Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE), the clinical benefit of early and intermediate-term use of combined antiplatelet agents--clopidogrel plus aspirin--in non-ST-segment elevation myocardial infarction (NSTEMI) patients became evident. Pretreatment and intermediate-term therapy with clopidogrel in NSTEMI ACS patients undergoing percutaneous coronary intervention (PCI) was further supported by the PCI-CURE trial. Recently, the results of two major trials Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28, Clopidogrel and Metoprolol in Myocardial Infarction Trial established the pivotal role of clopidogrel in the other spectrum of ACS-STEMI. Coupled with the results from previous multicentre trials, these two studies provide a guide for the early and long-term use of clopidogrel in the whole spectrum of ACS. A review summarising the results of the recent clinical trials and a discussion on its implications for the clinical management of ACS is presented.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  3. Permsuwan U, Chaiyakunapruk N, Nathisuwan S, Sukonthasarn A
    Heart Lung Circ, 2015 Sep;24(9):860-8.
    PMID: 25837019 DOI: 10.1016/j.hlc.2015.02.018
    Non-ST elevation acute coronary syndrome (NSTE-ACS) imposes a significant health and economic burden on a society. Anticoagulants are recommended as standard therapy by various clinical practice guidelines. Fondaparinux was introduced and evaluated in a number of large randomised, controlled trials. This study therefore aimed to determine the cost-effectiveness of fondaparinux versus enoxaparin in the treatment of NSTE-ACS in Thailand.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  4. Khonsari S, Subramanian P, Chinna K, Latif LA, Ling LW, Gholami O
    Eur J Cardiovasc Nurs, 2015 Apr;14(2):170-9.
    PMID: 24491349 DOI: 10.1177/1474515114521910
    Medication non-adherence leads to a vast range of negative outcomes in patients with coronary artery disease. An automated web-based system managing short message service (SMS) reminders is a telemedicine approach to optimise adherence among patients who frequently forget to take their medications or miss the timing.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  5. Kassab Y, Hassan Y, Abd Aziz N, Ismail O, AbdulRazzaq H
    Int J Clin Pharm, 2013 Apr;35(2):275-80.
    PMID: 23283596 DOI: 10.1007/s11096-012-9735-y
    BACKGROUND: Secondary prevention pharmacotherapy improves outcomes after acute coronary syndrome (ACS). However, poor medication adherence is common, and various factors play a role in adherence.
    OBJECTIVES: The purpose of this study was to evaluate patients' level of adherence to evidence-based therapies at an average of 6 months after discharge for acs and to identify factors associated with self-reported non-adherence.
    SETTING: This prospective study was conducted in the outpatient cardiac clinics of Hospital Pulau Pinang, located in Penang Island, a northern state in Malaysia.
    METHOD: A random sample of ACS patients (n = 190) who had been discharged on a regimen of secondary preventive medications were included in this study. Six months after discharge and during their scheduled follow-up appointments to cardiac clinics, patients were interviewed using the translated eight-item Morisky Medication Adherence Scale.
    MAIN OUTCOME MEASURE: self-reported patients' adherence to medication.
    RESULTS: Six months following their hospital discharge, only 35 patients (18.4 %) reported high adherence. Medium adherence was reported in majority of patients (51.1 %). Low adherence was reported in 58 patients (30.5 %). Forgetfulness was the most frequently reported reason for patients' non-adherence to their medications (23.2 %). Furthermore, this study identified 5 factors-namely age, employment status, ACS subtypes, number of comorbidities, and number of prescription medications per day-that may influence Patients' level of adherence to the prescribed regimens.
    CONCLUSIONS: Our findings revealed a problem of non-adherence to secondary prevention medications among patients with ACS in Malaysia. Furthermore, this study demonstrates that older patients, unemployed patients, patients with more comorbid conditions, and those receiving multiple medications are less likely to adhere to their prescribed medications 6 months after hospital discharge.

    Study site: outpatient cardiac clinics of Hospital Pulau Pinang
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  6. Akkaif MA, Ng ML, Sk Abdul Kader MA, Daud NAA, Sha'aban A, Ibrahim B
    Pharmacol Rep, 2021 Dec;73(6):1551-1564.
    PMID: 34283374 DOI: 10.1007/s43440-021-00309-0
    BACKGROUND: Ticagrelor is an oral antiplatelet drug that can reversibly bind to the platelet P2Y12 receptor. Ticagrelor is metabolized mainly by CYP3A4 and produces a rapid blood concentration-dependent platelet inhibitory effect. Unlike other P2Y12 receptor antagonists, many clinical features of ticagrelor are not related to P2Y12 receptor antagonism.

    PURPOSE: This review aims to gather existing literature on the clinical effects of ticagrelor after inhibiting adenosine uptake.

    METHODOLOGY: The current study reviewed literature related to the effects of ticagrelor on adenosine metabolism. The review also examined the drug's biological effects and clinical characteristics to see how it could be used in a clinical setting.

    RESULTS: Many studies have shown that ticagrelor can inhibit equilibrative nucleoside transporter 1 (ENT1). This inhibition leads to intracellular adenosine uptake, increased adenosine half-life and plasma concentration levels and an enhanced adenosine-mediated biological effect.

    CONCLUSIONS: Based on the studies reviewed, it was found that ticagrelor essentially inhibits adenosine absorption of adenosine into cells through ENT1, which increases the concentration in the blood and subsequently increases the protection of the heart muscle by adenosine. It also prevents platelet aggregation, and extends the biological effects of coronary arteries. Moreover, it leads to a lower mortality rate in acute coronary syndrome (ACS) patients.

    Matched MeSH terms: Acute Coronary Syndrome/drug therapy
  7. Biswas M, Kali MSK, Biswas TK, Ibrahim B
    Platelets, 2021 Jul 04;32(5):591-600.
    PMID: 32664772 DOI: 10.1080/09537104.2020.1792871
    The most effective antiplatelet treatments for acute coronary syndrome (ACS) patients carrying CYP2C19 loss-of-function (LoF) alleles undergoing percutaneous coronary intervention (PCI) is still debating and conflicting. It was aimed to compare the efficacy and safety endpoints for these patients treated with alternative P2Y12 receptor blockers (e.g. prasugrel or ticagrelor) against clopidogrel. Literature was searched in PubMed, Cochrane library, Synapse and 1000 Genomes databases following PRISMA guidelines for identifying relevant studies. Aggregated risk was estimated by RevMan software using either fixed/random-effects models where P values<0.05 (two-sided) were considered statistically significant. Nine studies comprising 16,132 ACS patients undergoing PCI were included in this analysis in which 2,746 and 2,640 patients were in the CYP2C19 LoF clopidogrel and alternatives treatment group, respectively. It was demonstrated that patients treated with prasugrel or ticagrelor significantly reduced the risk of MACEs (RR 0.58; 95% CI 0.45-0.76; P<0.0001) as compared to patients with clopidogrel where both groups carrying CYP2C19 LoF alleles. Subgroup analysis showed that prasugrel or ticagrelor significantly reduced the risk of cardiovascular death (RR 0.44; 95% CI: 0.25-0.74; P=0.002) and MI (RR 0.60; 95% CI: 0.44-0.81; P=0.0008) while other clinical outcomes were not found statistically significant between these two groups; stroke (RR 0.77; 95% CI: 0.43-1.38; P =0.39), stent thrombosis (RR 0.67; 95% CI: 0.38-1.18; P =0.17), unstable angina (RR 0.55; 95% CI: 0.13-2.33; P =0.42), revascularisation (RR 0.79; 95% CI: 0.28-2.24; P=0.66). Bleeding events were not found significantly different between these groups (RR 1.06; 95% CI: 0.88-1.28; P=0.55). Considering efficacy and safety, alternative antiplatelets (e.g. prasugrel or ticagrelor) may be regarded as better treatment option as compared to clopidogrel for ACS patients undergoing PCI.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  8. Tan HJ
    J Dig Dis, 2010 Dec;11(6):334-42.
    PMID: 21091895 DOI: 10.1111/j.1751-2980.2010.00466.x
    A proton pump inhibitor (PPI) is often co-prescribed with clopidogrel to reduce the gastrointestinal risk of bleeding ulcers in patients following acute coronary syndrome or a stent implant. However, the safety issue of such practice has been scrutinized after some studies reporting an increased incidence of cardiovascular events and mortality, although there have also been contrary research reports. This has lead to a warning statement from the US Food and Drug Administration cautioning the concomitant use of PPI and clopidogrel. This review examines the evidence of PPI as gastroprotective agent, histamine H(2) antagonists as an alternative therapy, the influence of PPI on the antiplatelet effect of clopidogrel, and the controversies of various studies.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  9. Chin SP, Jeyaindran S, Azhari R, Wan Azman WA, Omar I, Robaayah Z, et al.
    Med J Malaysia, 2008 Sep;63 Suppl C:29-36.
    PMID: 19230244
    Coronary artery disease is one of the most rampant non-communicable diseases in the world. It begins indolently as a fatty streak in the lining of the artery that soon progresses to narrow the coronary arteries and impair myocardial perfusion. Often the atherosclerotic plaque ruptures and causes sudden thrombotic occlusion and acute ST-elevation myocardial infarction (STEMI), non-ST-elevation MI (NSTEMI) or unstable angina (UA). This phenomenon is called acute coronary syndrome (ACS) and is the leading cause of death not only in Malaysia but also globally. In order for us to tackle this threat to the health of our nation we must arm ourselves with reliable and accurate information to assess current burden of disease resources available and success of current strategies. The acute coronary syndrome (ACS) registry is the flagship of the National Cardiovascular Disease Database (NCVD) and is the result of the dedicated and untiring efforts of doctors and nurses in both public and private medical institutions and hospitals around the country, ably guided and supported by the National Heart Association, the National Heart Foundation, the Clinical Research Centre and the Ministry of Health of Malaysia. Analyses of data collected throughout 2006 from 3422 patients with ACS admitted to the 12 tertiary cardiac centres and general hospitals spanning nine states in Malaysia in this first report has already revealed surprising results. Mean age of patients was 59 years while the most consistent risk factor for STEMI was active smoking. Utilization of medications was high generally. Thirty-day mortality for STEMI was 11%, for NSTEMI 8% and UA 4%. Thrombolysis (for STEMI only) reduced in-hospital and 30-day mortality by nearly 50%. Percutaneous coronary intervention or PCI also reduced 30-day mortality for patients with non-ST elevation MI and unstable angina. The strongest determinants of mortality appears to be Killip Class and age of the patient. Fewer women received thrombolysis or underwent PCI on same admission although women make up 25% of the cohort.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy
  10. Hassan Y, Kassab Y, Abd Aziz N, Akram H, Ismail O
    J Clin Pharm Ther, 2013 Apr;38(2):97-100.
    PMID: 23441979 DOI: 10.1111/jcpt.12027
    Pharmacists have the knowledge regarding optimal use of medications and the ability to influence physician prescribing. Successful interventions by a pharmacist to implement cardioprotective medications to a coronary artery disease patient's regimen would not only improve the patient's quality of care but may also increase his or her likelihood of survival. Therefore, the aim of this study was to (i) evaluate the effectiveness of pharmacist initiated interventions in increasing the prescription rates of acute coronary syndrome (ACS) secondary prevention pharmacotherapy at discharge, and to (ii) evaluate the acceptance rate of these interventions by prescribers.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  11. Serebruany V, Tanguay JF, Benavides MA, Cabrera-Fuentes H, Eisert W, Kim MH, et al.
    Am J Ther, 2020 10 29;27(6):e563-e572.
    PMID: 33109913 DOI: 10.1097/MJT.0000000000001286
    BACKGROUND: Excess vascular deaths in the PLATO trial comparing ticagrelor to clopidogrel have been repeatedly challenged by the Food and Drug Administration (FDA) reviewers and academia. Based on the Freedom of Information Act, BuzzFeed won a court order and shared with us the complete list of reported deaths for the ticagrelor FDA New Drug Application (NDA) 22-433. This dataset was matched against local patient-level records from PLATO sites monitored by the sponsor.

    STUDY QUESTION: Whether FDA death data in the PLATO trial matched the local site records.

    STUDY DESIGN: The NDA spreadsheet contains 938 precisely detailed PLATO deaths. We obtained and validated local evidence for 52 deaths among 861 PLATO patients from 14 enrolling sites in 8 countries and matched those with the official NDA dataset submitted to the FDA.

    MEASURES AND OUTCOMES: Existence, precise time, and primary cause of deaths in PLATO.

    RESULTS: Discrepant to the NDA document, sites confirmed 2 extra unreported deaths (Poland and Korea) and failed to confirm 4 deaths (Malaysia). Of the remaining 46 deaths, dates were reported correctly for 42 patients, earlier (2 clopidogrel), or later (2 ticagrelor) than the actual occurrence of death. In 12 clopidogrel patients, cause of death was changed to "vascular," whereas 6 NDA ticagrelor "nonvascular" or "unknown" deaths were site-reported as of "vascular" origin. Sudden death was incorrectly reported in 4 clopidogrel patients, but omitted in 4 ticagrelor patients directly affecting the primary efficacy PLATO endpoint.

    CONCLUSIONS: Many deaths were inaccurately reported in PLATO favoring ticagrelor. The full extent of mortality misreporting is currently unclear, while especially worrisome is a mismatch in identifying primary death cause. Because all PLATO events are kept in the cloud electronic Medidata Rave capture system, securing the database content, examining the dataset changes or/and repeated entries, identifying potential interference origin, and assessing full magnitude of the problem are warranted.

    Matched MeSH terms: Acute Coronary Syndrome/drug therapy
  12. Lee CY, Liu KT, Lu HT, Mohd Ali R, Fong AYY, Wan Ahmad WA
    PLoS One, 2021;16(2):e0246474.
    PMID: 33556136 DOI: 10.1371/journal.pone.0246474
    BACKGROUND: Sex and gender differences in acute coronary syndrome (ACS) have been well studied in the western population. However, limited studies have examined the trends of these differences in a multi-ethnic Asian population.

    OBJECTIVES: To study the trends in sex and gender differences in ACS using the Malaysian NCVD-ACS Registry.

    METHODS: Data from 24 hospitals involving 35,232 ACS patients (79.44% men and 20.56% women) from 1st. Jan 2012 to 31st. Dec 2016 were analysed. Data were collected on demographic characteristics, coronary risk factors, anthropometrics, treatments and outcomes. Analyses were done for ACS as a whole and separately for ST-segment elevation myocardial infarction (STEMI), Non-STEMI and unstable angina. These were then compared to published data from March 2006 to February 2010 which included 13,591 ACS patients (75.8% men and 24.2% women).

    RESULTS: Women were older and more likely to have diabetes mellitus, hypertension, dyslipidemia, previous heart failure and renal failure than men. Women remained less likely to receive aspirin, beta-blocker, angiotensin-converting enzyme inhibitor (ACE-I) and statin. Women were less likely to undergo angiography and percutaneous coronary intervention (PCI) despite an overall increase. In the STEMI cohort, despite a marked increase in presentation with Killip class IV, women were less likely to received primary PCI or fibrinolysis and had longer median door-to-needle and door-to-balloon time compared to men, although these had improved. Women had higher unadjusted in-hospital, 30-Day and 1-year mortality rates compared to men for the STEMI and NSTEMI cohorts. After multivariate adjustments, 1-year mortality remained significantly higher for women with STEMI (adjusted OR: 1.31 (1.09-1.57), p<0.003) but were no longer significant for NSTEMI cohort.

    CONCLUSION: Women continued to have longer system delays, receive less aggressive pharmacotherapies and invasive treatments with poorer outcome. There is an urgent need for increased effort from all stakeholders if we are to narrow this gap.

    Matched MeSH terms: Acute Coronary Syndrome/drug therapy
  13. Ahmad WA, Ramesh SV, Zambahari R
    Singapore Med J, 2011 Jul;52(7):508-11.
    PMID: 21808962
    The ACute CORonary syndromes Descriptive study (ACCORD) is a prospective observational study that evaluates the management of acute coronary syndrome (ACS) in clinical practice and the use of antiplatelet agents in acute settings and after discharge. The secondary objective of this study was to obtain information on risk factors in a large cohort of patients with ACS.
    Comment in: Sachithanandan A. Malaysia-ACCORD study: tip of the cardiovascular iceberg--we must do better. Singapore Med J, 2011 Sep;52(9):702;
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy
  14. Lee YY, Tee MH, Zurkurnai Y, Than W, Sapawi M, Suhairi I
    Singapore Med J, 2008 Apr;49(4):304-10.
    PMID: 18418522
    This study was primarily aimed to determine the failure rate of thrombolysis with streptokinase in acute myocardial infarction using electrocardiogram criteria and its association between various independent variables and outcome parameters.
    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
  15. Huo Y, Lee SW, Sawhney JP, Kim HS, Krittayaphong R, Nhan VT, et al.
    Clin Cardiol, 2015 Sep;38(9):511-9.
    PMID: 26206158 DOI: 10.1002/clc.22431
    BACKGROUND: In-hospital and postdischarge mortality for acute coronary syndromes (ACS) vary across Asia and remain generally poorer than globally. The relationship between real-life antithrombotic management patterns (AMPs) and ACS-related outcomes in Asia is unclear.

    METHODS: EPICOR Asia (Long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) (NCT01361386) is a prospective, multinational, observational study of patients discharged after hospitalization for an ACS, with 2-year follow-up. The aim is to describe short- and long-term (up to 2 years post-index event) AMPs in patients hospitalized for ACS and to record clinical outcomes, healthcare resource use, and self-reported health status. Pre- and in-hospital management, AMPs, and associated outcomes, with particular focus on ischemic and bleeding events, will be recorded during the 2-year follow up.

    RESULTS: Between June 2011 and May 2012, 13 005 patients were enrolled. From these, 12 922 patients surviving an ACS (6616 with STEMI, 2570 with NSTEMI, and 3736 with UA) were eligible for inclusion from 219 hospitals across 8 countries and regions in Asia: China (n = 8214), Hong Kong (n = 177), India (n = 2468), Malaysia (n = 100), Singapore (n = 93), South Korea (n = 705), Thailand (n = 957), and Vietnam (n = 208).

    CONCLUSIONS: EPICOR Asia will provide information regarding clinical management and AMPs for ACS patients in Asia. Impact of AMPs on clinical outcomes, healthcare resource use, and self-reported health status both during hospitalization and up to 2 years after discharge will also be described.

    Matched MeSH terms: Acute Coronary Syndrome/drug therapy*
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