Dual Antiplatelet Therapy in Patients with Diabetes and Acute Coronary Syndromes Managed without Revascularization
Abstract Objective Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT...
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| Veröffentlicht in: | The American heart journal 2017-06, Vol.188, p.156-166 |
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| creator | Dalby, Anthony J Gottlieb, Shmuel Cyr, Derek D Magnus Ohman, E McGuire, Darren K Ruzyllo, Witold Bhatt, Deepak L Wiviott, Stephen D Winters, Kenneth J Fox, Keith A.A Armstrong, Paul W White, Harvey D Prabhakaran, Dorairaj Roe, Matthew T |
| description | Abstract Objective Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain. Methods The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30 months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. Results Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30 months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM ( P int = 0.82) and with or without insulin treatment among those with DM ( P int = 0.304). Conclusions Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel. |
| doi_str_mv | 10.1016/j.ahj.2017.03.015 |
| format | Article |
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The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain. Methods The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30 months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. Results Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30 months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM ( P int = 0.82) and with or without insulin treatment among those with DM ( P int = 0.304). Conclusions Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel.</description><identifier>ISSN: 0002-8703</identifier><identifier>EISSN: 1097-6744</identifier><identifier>DOI: 10.1016/j.ahj.2017.03.015</identifier><identifier>PMID: 28577671</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Acute Coronary Syndrome - drug therapy ; Acute coronary syndromes ; Aged ; Amplification ; Angina pectoris ; Aspirin ; Aspirin - administration & dosage ; Attitude control ; Blood clots ; Blood platelets ; Cardiovascular ; Cardiovascular disease ; Cerebral infarction ; Clinical outcomes ; Clopidogrel ; Coronary vessels ; Death ; Diabetes ; Diabetes mellitus ; Diabetes Mellitus - drug therapy ; Disorders ; Dose-Response Relationship, Drug ; Double-Blind Method ; Drug therapy ; Drug Therapy, Combination ; Electrocardiography ; Female ; Follow-Up Studies ; Heart attacks ; Humans ; Insulin ; Intervention ; Ischemia ; Male ; Mortality ; Myocardial infarction ; Myocardial Revascularization ; Patients ; Platelet Aggregation Inhibitors - administration & dosage ; Prasugrel Hydrochloride - administration & dosage ; Risk assessment ; Risk management ; Stroke ; Therapy ; Ticlopidine - administration & dosage ; Ticlopidine - analogs & derivatives ; Time Factors ; Treatment Outcome</subject><ispartof>The American heart journal, 2017-06, Vol.188, p.156-166</ispartof><rights>2017 Elsevier Inc.</rights><rights>Copyright © 2017 Elsevier Inc. All rights reserved.</rights><rights>Copyright Elsevier Limited Jun 1, 2017</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c436t-f00a92ed96a499161d8e32467bf4a87a3ab73f4d4e52a11d673986d2a02be0a33</citedby><cites>FETCH-LOGICAL-c436t-f00a92ed96a499161d8e32467bf4a87a3ab73f4d4e52a11d673986d2a02be0a33</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0002870317301084$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65534</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28577671$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Dalby, Anthony J</creatorcontrib><creatorcontrib>Gottlieb, Shmuel</creatorcontrib><creatorcontrib>Cyr, Derek D</creatorcontrib><creatorcontrib>Magnus Ohman, E</creatorcontrib><creatorcontrib>McGuire, Darren K</creatorcontrib><creatorcontrib>Ruzyllo, Witold</creatorcontrib><creatorcontrib>Bhatt, Deepak L</creatorcontrib><creatorcontrib>Wiviott, Stephen D</creatorcontrib><creatorcontrib>Winters, Kenneth J</creatorcontrib><creatorcontrib>Fox, Keith A.A</creatorcontrib><creatorcontrib>Armstrong, Paul W</creatorcontrib><creatorcontrib>White, Harvey D</creatorcontrib><creatorcontrib>Prabhakaran, Dorairaj</creatorcontrib><creatorcontrib>Roe, Matthew T</creatorcontrib><creatorcontrib>for the TRILOGY ACS Investigators</creatorcontrib><creatorcontrib>TRILOGY ACS Investigators</creatorcontrib><title>Dual Antiplatelet Therapy in Patients with Diabetes and Acute Coronary Syndromes Managed without Revascularization</title><title>The American heart journal</title><addtitle>Am Heart J</addtitle><description>Abstract Objective Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain. Methods The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30 months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. Results Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30 months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM ( P int = 0.82) and with or without insulin treatment among those with DM ( P int = 0.304). Conclusions Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel.</description><subject>Acute Coronary Syndrome - drug therapy</subject><subject>Acute coronary syndromes</subject><subject>Aged</subject><subject>Amplification</subject><subject>Angina pectoris</subject><subject>Aspirin</subject><subject>Aspirin - administration & dosage</subject><subject>Attitude control</subject><subject>Blood clots</subject><subject>Blood platelets</subject><subject>Cardiovascular</subject><subject>Cardiovascular disease</subject><subject>Cerebral infarction</subject><subject>Clinical outcomes</subject><subject>Clopidogrel</subject><subject>Coronary vessels</subject><subject>Death</subject><subject>Diabetes</subject><subject>Diabetes mellitus</subject><subject>Diabetes Mellitus - drug therapy</subject><subject>Disorders</subject><subject>Dose-Response Relationship, Drug</subject><subject>Double-Blind Method</subject><subject>Drug therapy</subject><subject>Drug Therapy, Combination</subject><subject>Electrocardiography</subject><subject>Female</subject><subject>Follow-Up Studies</subject><subject>Heart attacks</subject><subject>Humans</subject><subject>Insulin</subject><subject>Intervention</subject><subject>Ischemia</subject><subject>Male</subject><subject>Mortality</subject><subject>Myocardial infarction</subject><subject>Myocardial Revascularization</subject><subject>Patients</subject><subject>Platelet Aggregation Inhibitors - administration & dosage</subject><subject>Prasugrel Hydrochloride - administration & dosage</subject><subject>Risk assessment</subject><subject>Risk management</subject><subject>Stroke</subject><subject>Therapy</subject><subject>Ticlopidine - administration & dosage</subject><subject>Ticlopidine - analogs & derivatives</subject><subject>Time Factors</subject><subject>Treatment Outcome</subject><issn>0002-8703</issn><issn>1097-6744</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2017</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>8G5</sourceid><sourceid>BENPR</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNp9kk9vEzEQxVcIREPhA3BBlrhwSRj_ib0rJKQopYBUBKLlbE3WE-Kw8aa2tyh8-npJAakHTtbIv_c0M2-q6jmHGQeuX29nuNnOBHAzAzkDPn9QTTg0ZqqNUg-rCQCIaW1AnlRPUtqWUotaP65ORD03Rhs-qeLZgB1bhOz3HWbqKLOrDUXcH5gP7AtmTyEn9tPnDTvzuKJMiWFwbNEOmdiyj33AeGCXh-BivyufnzDgd3K_Jf2Q2Ve6wdQOHUb_q9j14Wn1aI1domd372n17fzd1fLD9OLz-4_LxcW0VVLn6RoAG0Gu0aiahmvuapJCabNaK6wNSlwZuVZO0Vwg504b2dTaCQSxIkApT6tXR9997K8HStnufGqp6zBQPyTLG9BcgeCioC_vodt-iKF0N1KqlnzejIb8SLWxTynS2u6j35XpLQc7BmK3tgRix0AsSFsCKZoXd87Dakfur-JPAgV4cwSorOLGU7SpLTtvyflIbbau9_-1f3tP3XY--Ba7H3Sg9G8Km4QFezlexHgQ3EjgUCt5C84nsHo</recordid><startdate>20170601</startdate><enddate>20170601</enddate><creator>Dalby, Anthony J</creator><creator>Gottlieb, Shmuel</creator><creator>Cyr, Derek D</creator><creator>Magnus Ohman, E</creator><creator>McGuire, Darren K</creator><creator>Ruzyllo, Witold</creator><creator>Bhatt, Deepak L</creator><creator>Wiviott, Stephen D</creator><creator>Winters, Kenneth J</creator><creator>Fox, Keith A.A</creator><creator>Armstrong, Paul W</creator><creator>White, Harvey D</creator><creator>Prabhakaran, Dorairaj</creator><creator>Roe, Matthew T</creator><general>Elsevier Inc</general><general>Elsevier Limited</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QO</scope><scope>7RV</scope><scope>7TS</scope><scope>7X7</scope><scope>7XB</scope><scope>88C</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AN0</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M0T</scope><scope>M1P</scope><scope>M2O</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>P64</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>Q9U</scope><scope>7X8</scope></search><sort><creationdate>20170601</creationdate><title>Dual Antiplatelet Therapy in Patients with Diabetes and Acute Coronary Syndromes Managed without Revascularization</title><author>Dalby, Anthony J ; Gottlieb, Shmuel ; Cyr, Derek D ; Magnus Ohman, E ; McGuire, Darren K ; Ruzyllo, Witold ; Bhatt, Deepak L ; Wiviott, Stephen D ; Winters, Kenneth J ; Fox, Keith A.A ; Armstrong, Paul W ; White, Harvey D ; Prabhakaran, Dorairaj ; Roe, Matthew T</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c436t-f00a92ed96a499161d8e32467bf4a87a3ab73f4d4e52a11d673986d2a02be0a33</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2017</creationdate><topic>Acute Coronary Syndrome - drug therapy</topic><topic>Acute coronary syndromes</topic><topic>Aged</topic><topic>Amplification</topic><topic>Angina pectoris</topic><topic>Aspirin</topic><topic>Aspirin - administration & dosage</topic><topic>Attitude control</topic><topic>Blood clots</topic><topic>Blood platelets</topic><topic>Cardiovascular</topic><topic>Cardiovascular disease</topic><topic>Cerebral infarction</topic><topic>Clinical outcomes</topic><topic>Clopidogrel</topic><topic>Coronary vessels</topic><topic>Death</topic><topic>Diabetes</topic><topic>Diabetes mellitus</topic><topic>Diabetes Mellitus - drug therapy</topic><topic>Disorders</topic><topic>Dose-Response Relationship, Drug</topic><topic>Double-Blind Method</topic><topic>Drug therapy</topic><topic>Drug Therapy, Combination</topic><topic>Electrocardiography</topic><topic>Female</topic><topic>Follow-Up Studies</topic><topic>Heart attacks</topic><topic>Humans</topic><topic>Insulin</topic><topic>Intervention</topic><topic>Ischemia</topic><topic>Male</topic><topic>Mortality</topic><topic>Myocardial infarction</topic><topic>Myocardial Revascularization</topic><topic>Patients</topic><topic>Platelet Aggregation Inhibitors - administration & dosage</topic><topic>Prasugrel Hydrochloride - administration & dosage</topic><topic>Risk assessment</topic><topic>Risk management</topic><topic>Stroke</topic><topic>Therapy</topic><topic>Ticlopidine - administration & dosage</topic><topic>Ticlopidine - analogs & derivatives</topic><topic>Time Factors</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Dalby, Anthony J</creatorcontrib><creatorcontrib>Gottlieb, Shmuel</creatorcontrib><creatorcontrib>Cyr, Derek D</creatorcontrib><creatorcontrib>Magnus Ohman, E</creatorcontrib><creatorcontrib>McGuire, Darren K</creatorcontrib><creatorcontrib>Ruzyllo, Witold</creatorcontrib><creatorcontrib>Bhatt, Deepak L</creatorcontrib><creatorcontrib>Wiviott, Stephen D</creatorcontrib><creatorcontrib>Winters, Kenneth J</creatorcontrib><creatorcontrib>Fox, Keith A.A</creatorcontrib><creatorcontrib>Armstrong, Paul W</creatorcontrib><creatorcontrib>White, Harvey D</creatorcontrib><creatorcontrib>Prabhakaran, Dorairaj</creatorcontrib><creatorcontrib>Roe, Matthew T</creatorcontrib><creatorcontrib>for the TRILOGY ACS Investigators</creatorcontrib><creatorcontrib>TRILOGY ACS Investigators</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Physical Education Index</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Healthcare Administration Database (Alumni)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>British Nursing Database</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Healthcare Administration Database</collection><collection>Medical Database</collection><collection>Research Library</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><jtitle>The American heart journal</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Dalby, Anthony J</au><au>Gottlieb, Shmuel</au><au>Cyr, Derek D</au><au>Magnus Ohman, E</au><au>McGuire, Darren K</au><au>Ruzyllo, Witold</au><au>Bhatt, Deepak L</au><au>Wiviott, Stephen D</au><au>Winters, Kenneth J</au><au>Fox, Keith A.A</au><au>Armstrong, Paul W</au><au>White, Harvey D</au><au>Prabhakaran, Dorairaj</au><au>Roe, Matthew T</au><aucorp>for the TRILOGY ACS Investigators</aucorp><aucorp>TRILOGY ACS Investigators</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Dual Antiplatelet Therapy in Patients with Diabetes and Acute Coronary Syndromes Managed without Revascularization</atitle><jtitle>The American heart journal</jtitle><addtitle>Am Heart J</addtitle><date>2017-06-01</date><risdate>2017</risdate><volume>188</volume><spage>156</spage><epage>166</epage><pages>156-166</pages><issn>0002-8703</issn><eissn>1097-6744</eissn><abstract>Abstract Objective Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain. Methods The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30 months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. Results Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30 months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM ( P int = 0.82) and with or without insulin treatment among those with DM ( P int = 0.304). Conclusions Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28577671</pmid><doi>10.1016/j.ahj.2017.03.015</doi><tpages>11</tpages></addata></record> |
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| subjects | Acute Coronary Syndrome - drug therapy Acute coronary syndromes Aged Amplification Angina pectoris Aspirin Aspirin - administration & dosage Attitude control Blood clots Blood platelets Cardiovascular Cardiovascular disease Cerebral infarction Clinical outcomes Clopidogrel Coronary vessels Death Diabetes Diabetes mellitus Diabetes Mellitus - drug therapy Disorders Dose-Response Relationship, Drug Double-Blind Method Drug therapy Drug Therapy, Combination Electrocardiography Female Follow-Up Studies Heart attacks Humans Insulin Intervention Ischemia Male Mortality Myocardial infarction Myocardial Revascularization Patients Platelet Aggregation Inhibitors - administration & dosage Prasugrel Hydrochloride - administration & dosage Risk assessment Risk management Stroke Therapy Ticlopidine - administration & dosage Ticlopidine - analogs & derivatives Time Factors Treatment Outcome |
| title | Dual Antiplatelet Therapy in Patients with Diabetes and Acute Coronary Syndromes Managed without Revascularization |
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