METHODS: A systematic review and meta-analysis was performed in accordance with the PRISMA statement. MEDLINE, EMBASE and Cochrane Library were searched for completed manuscripts until May 2019 on TIA/ischaemic stroke patients, ≥ 18 years, treated with commonly-prescribed antiplatelet therapy, who had platelet function/reactivity testing and prospective follow-up data on recurrent stroke/TIA, myocardial infarction, vascular death or other cerebrovascular outcomes. Data were pooled using random-effects meta-analysis. Primary outcome was the composite risk of recurrent stroke/TIA, myocardial infarction or vascular death. Secondary outcomes were recurrent stroke/TIA, severe stroke (NIHSS > 16) or disability/impairment (modified Rankin scale ≥ 3) during follow-up.
RESULTS: Antiplatelet-HTPR prevalence was 3-65% with aspirin, 8-56% with clopidogrel and 1.8-35% with aspirin-clopidogrel therapy. Twenty studies (4989 patients) were included in our meta-analysis. There was a higher risk of the composite primary outcome (OR 2.93, 95% CI 1.90-4.51) and recurrent ischaemic stroke/TIA (OR 2.43, 95% CI 1.51-3.91) in patients with vs. those without 'antiplatelet-HTPR' on any antiplatelet regimen. These risks were also more than twofold higher in patients with vs. those without 'aspirin-HTPR' and 'dual antiplatelet-HTPR', respectively. Clopidogrel-HTPR status did not significantly predict outcomes, but the number of eligible studies was small. The risk of severe stroke was higher in those with vs. without antiplatelet-HTPR (OR 2.65, 95% CI 1.00-7.01).
DISCUSSION: Antiplatelet-HTPR may predict risks of recurrent vascular events/outcomes in CVD patients. Given the heterogeneity between studies, further prospective, multi-centre studies are warranted.
MATERIALS AND METHODS: We searched electronic databases. All available randomized controlled trials (RCTs) were included, and we considered the scientific novelty of the study, the reliability of the reported study results; the high methodological level of the study of non-statin therapy in patients with dyslipidemia and high residual platelet reactivity, with no language or date restrictions. We did separate random-effects meta-analyses for LDL-С, HRRP on their effects on LDL-С levels and outcomes, taking into account the reliability of the reported study results and the high methodological level of the study. The challenge of achieving target LDL-С levels, their impact on high residual platelet reactivity, and the choice of optimal antiplatelet and lipid-lowering therapy remains unresolved.
RESULTS: The integration of newer therapies, such as inclisiran and PCSK9 inhibitors, may play a critical role in achieving optimal outcomes for patients at high cardiovascular risk.
CONCLUSION: The necessity of applying an individual multidisciplinary approach in order to determine the best regimen of antiplatelet and lipid-lowering therapy in patients with coronary heart disease, including after revascularization, is shown. This approach will reduce the risk of recurrent cardiovascular events. Few studies on the relationship between LDL-С and HRPR dictate the need for more detailed research in this area.
OBJECTIVES: This study across 17 high-, middle- and low-income countries described variations in secondary CVD prevention medication use over a median follow-up of 12 years.
METHODS: In the multinational PURE (Prospective Urban Rural Epidemiology) cohort study, we conducted a repeated cross-sectional analysis to examine temporal variations in the use of secondary prevention medications in participants with CVD. In participants with coronary artery disease, we focused on antiplatelet agents, statins, renin-angiotensin system (RAS) inhibitors, and β-blockers. In participants with stroke, we focused on antiplatelet agents, statins, RAS inhibitors, and other blood pressure-lowering drugs. Medications were collected at baseline and on 4 subsequent follow-up visits.
RESULTS: The analysis included 7,409 participants with a diagnosis of CVD at the baseline visit, 8,792 at the second visit, 9,236 at the third visit, 11,082 at the fourth visit, and 11,677 at the last visit. The median age at baseline was 58.0 years, and 52.9% of the participants were female. The median follow-up was 12 years, with the median year of the baseline visit in 2007 and the fifth visit in 2019. Over this period, use of 1 or more classes of medications for secondary CVD prevention was 41.3% (95% CI: 40.2%-42.4%) at baseline, peaked at 43.1% (95% CI: 42.0%-44.1%), and then decreased to 31.3% (95% CI: 30.4%-32.1%) by the last study visit. In high-income countries, this use decreased from 88.8% (95% CI: 86.6%-91.0%) to 77.3% (95% CI: 74.9%-79.6%). In upper-middle-income countries, this use increased from 55.0% (95% CI: 52.8%-57.3%) to 61.1% (95% CI: 59.1%-63.1%). In lower-middle-income countries, use of at least 1 class of medications was 29.5% (95% CI: 28.1%-30.9%) at baseline, peaked at 31.7% (95% CI: 30.4%-33.1%), and then decreased to 13.4% (95% CI: 12.5%-14.2%) by the last visit. In low-income countries, use of at least 1 class of medications was 20.8% (95% CI: 18.1%-23.5%) at baseline, peaked at 47.3% (95% CI: 44.8%-49.9%), and then decreased to 27.5% (95% CI: 25.2%-29.9%) by the last study visit.
CONCLUSIONS: Globally and in most country income-level groups, the use of medications for secondary CVD prevention has been low, with little improvement over time.
METHODS: From Malaysian National Stroke Registry, we included patients with non-fatal ischemic stroke. Prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs were assessed. Multi-level logistic regressions were performed to determine the relation between potential factors and drug prescriptions.
RESULTS: Of 5292 patients, 48% received antihypertensive drugs, 88.9% antiplatelet and 88.7% lipid-lowering drugs upon discharge. Thirty-three percent of patients with an indication for anticoagulants (n = 391) received it. Compared to patients <=50 years, patients above 70 years were less likely to receive antiplatelet (OR: 0.72, 95% CI: 0.50-1.03), lipid-lowering drugs (OR: 0.66, 95% CI: 0.45-0.95) and anticoagulants (OR: 0.27, 95% CI: 0.09-0.83). Patients with moderate to severe disability upon discharge had less odds of receiving secondary preventive drugs; an odds ratio of 0.57 (95% CI: 0.45-0.71) for antiplatelet, 0.86 (95% CI: 0.75-0.98) for antihypertensive drugs and 0.78 (95% CI: 0.63-0.97) for lipid-lowering drugs in comparison to those with minor disability. Having prior specific comorbidities and drug prescriptions significantly increased the odds of receiving these drugs. No differences were found between sexes and ethnicities.
CONCLUSIONS: Prescription of antihypertensive drugs and anticoagulants among ischemic stroke patients in Malaysia were suboptimal. Efforts to initiate regular clinical audits to evaluate the uptake and effectiveness of secondary preventive strategies are timely in low and middle-income settings.
METHODS: A 44-year-old male, who had staged PCI to left anterior descending (LAD) 2 weeks after an anterior MI, with a drug-coated stent was readmitted with new anterior STEMI 35 days later. Coronary angiogram revealed mid-stent thrombus in situ. He had further uncomplicated PCI. Platelet function testing and genotyping showed clopidogrel high on-treatment platelet reactivity and CYP2C19*3/*17 genotype. Ticagrelor was commenced.
RESULTS & CONCLUSION: This case study is the first reported in Malaysia to document a patient with a CYP2C19*3/*17 genotype presenting with a stent thrombosis after an uncomplicated index PCI procedure.