Współczesne wykorzystanie tikagreloru w ośrodkach medycznych w Polsce jako odzwierciedlenie przestrzegania wytycznych dotyczących terapii przeciwpłytkowej

Introduction. Ticagrelor is the newest P2Y12 inhibitor recommended as the first treatment option for acute myocardial infarction both with and without ST-segment elevation. Recent studies have revealed unsatisfactory use of novel P2Y12 inhibitors. The aim of our study was to assess the contemporary use of ticagrelor in major medical centres located in Kuyavian-Pomeranian, Pomeranian, and Warmian-Masurian voivodships. Materials and methods. Retrospective analysis of hospital records regarding the number of ticagrelor tablets purchased monthly was performed covering a three-year period from January 2015 to December 2017. Data from 15 major medical centres was analysed. Results. A total of 78,871 tablets of ticagrelor were purchased over the study period, with a monthly median of 2,013.5 and an interquartile range (IQR) of 1,255–2,996. The amount of ticagrelor increased monthly by 7.9%. The lowest monthly value (294, 0.37%) was recorded in the first month, while the highest (4,550, 5.77%) was in October 2017. The median of tablets purchased in 2017 (3,934, IQR 3,010–4,270) was over four times greater than in 2015 (980, IQR 728–1,288, p < 0.001) and more than double that in 2016 (1,689, IQR 1,353–2,479, p = 0.012). The highest reported amount of the drug in one centre (16,296, 20.6%) was 291 times greater than the amount in the centre with the lowest ticagrelor use (56, 0.07%, p = 0.27). Conclusions. The use of ticagrelor has been significantly increasing in recent years, which reflects the implementation of current guidelines by medical centres. Substantial heterogeneity regarding the use of ticagrelor is observed within particular centres.Wstęp. Tikagrelor to najnowszy doustny inhibitor receptora P2Y12 zalecany w leczeniu pierwszego rzutu w zawale sercazarówno z uniesieniem, jak i bez uniesienia odcinka ST. Ostatnie doniesienia wskazują na niezadowalające wykorzystaniew terapii nowych inhibitorów receptora P2Y12. Celem niniejszego badania była ocena współczesnego wykorzystaniatikagreloru w głównych ośrodkach medycznych zlokalizowanych na terenie województw kujawsko-pomorskiego, pomorskiegooraz warmińsko-mazurskiego.Materiały i metody. Przeprowadzono retrospektywną analizę danych pochodzących ze szpitalnych rejestrów, któredotyczyły miesięcznej liczby zakupionych tabletek tikagreloru. Badanie obejmowało okres 3 lat — od stycznia 2015 dogrudnia 2017 roku. Przeanalizowano dane pochodzące z 15 ośrodków medycznych. Wyniki. W trakcie okresu obserwacji kupiono w sumie 78 871 tabletek tikagreloru, a miesięczna mediana wyniosła2013,5 z przedziałem międzykwartylowym (IQR) 1255–2996. Ilość wykorzystywanego tikagreloru wzrastała miesięcznieo 7,9%. Najmniejszą ilość leku zarejestrowano w pierwszym miesiącu obserwacji (294; 0,37%), natomiast najwięcej tabletek(4550; 5,77%) kupiono w październiku 2017 roku. Mediana ilości tikagreloru w roku 2017 (3934, IQR 3010–4270)była ponad 4-krotnie większa od mediany w roku 2015 (980; IQR 728–1288; p &lt; 0,001) i ponad 2-krotnie większa odzaobserwowanej w 2016 roku (1689; IQR 1353–2479; p = 0,012). Ośrodek, w którym odnotowano największą sumarycznąilość zastosowanego tikagreloru (16 296; 20,6%), kupił w całym okresie obserwacji 291 razy więcej tabletek niżośrodek z najmniejszą zarejestrowaną ilością leku (56; 0,07%; p = 0,27).Wnioski. Wykorzystanie tikagreloru istotnie się zwiększyło w ostatnich latach, co odzwierciedla wprowadzanie docodziennej praktyki klinicznej zaleceń obecnych w aktualnych wytycznych dotyczących leczenia przeciwpłytkowego.Obserwuje się znaczne zróżnicowanie pod względem użycia tikagreloru w poszczególnych ośrodkach

Impact of health education on adherence to clopidogrel and clinical effectiveness of antiplatelet treatment in patients after myocardial infarction

Non-adherence rates to antiplatelet drugs in patients with acute myocardial infarction (AMI) range from 13% to 60%. We aimed to evaluate whether individual health education can improve adherence to treatment with clopidogrel in patients after AMI. This was a prospective, single-center, randomized clinical trial with a 12-month follow-up. Patients with AMI treated with percutaneous coronary intervention (PCI) were enrolled. The primary endpoint was defined as non-adherence to clopidogrel during follow-up (drug availability ≤ 80%). Secondary endpoints included platelet function assessment, adverse cardiovascular (CV) events (CV death, PCI for ACS, unscheduled CV hospitalization). There were 191 patients enrolled in the study and divided into two groups: the individual education (IE) group (100 patients) and the standard treatment (ST) group (91 patients). Adherence to the treatment with clopidogrel based on the data from the National Health Fund did not differ significantly between the IE and ST groups [76.7% (30.7–99.7%) v. 84.4% (46.5–99.7%); p = 0.25]. There was a substantial difference in the prevalence of unscheduled CV hospitalizations between both groups, IE and ST respectively [22 (22.0%) v. 10 (11.0%); p = 0.042]. The rate of CV death and ACS treated with PCI during follow-up was low and did not differ between groups. In conclusion, the program of individual health education did not improve adherence to treatment with clopidogrel. The expected benefits of medication are not achievable at current levels of adherence. The self-reported adherence assessment is unreliable and cannot be used for effective treatment guidance

Wpływ czynników klimatycznych i chronologicznych na występowanie ostrych incydentów chorobowych

Several studies revealed a relationship between the occurrence of acute life-threatening morbidities and both internal biological rhythms of the body, and some external factors such as the number of daylight hours, time of sunrise, sudden changes in the weather, temperature fluctuations, and changes in atmospheric pressure. The incidence of acute coronary syndromes exhibits a distinct seasonality, which is characterized by considerable geographical variation. Similarly, different weather factors influence the epidemiology of ischemic events in different climatic zones.Na podstawie licznych badań można stwierdzić, że występowanie stanów zagrożenia życia może się wiązać z wewnętrznymi rytmami organizmu, ale również z pewnymi czynnikami zewnętrznymi, takimi jak: liczba godzin ze światłem dziennym, czas wschodu słońca, gwałtowne zmiany pogody, wahania temperatur, zmiany ciśnienia atmosferycznego. Częstość występowania incydentów niedokrwienia serca wykazuje wyraźną sezonowość, którą cechuje znaczne zróżnicowanie geograficzne. Podobnie czynniki pogodowe odmiennie wpływają na epidemiologię ostrych zespołów wieńcowych w różnych strefach klimatycznych

Atmospheric conditions and the occurrence of out-of-hospital cardiac arrest in Poland — preliminary analysis of poorly understood phenomena

Background: The aim of this study was to investigate numerous daily weather conditions and the incidenceof out-of-hospital cardiac arrest (OHCA) in the moderate climate of Poland. The authors particularlywanted to examine yet poorly explored individual atmospheric parameters that may presumably influencethe incidence of OHCA. Methods: The retrospective analysis of OHCA cases based on dispatch cards from Emergency MedicalCentre in Opole, Poland covering 2 years (2006–2007). Total of 815 adults with presumed cardiac aetiologyof OHCA was included. Results: The mean age of the group was 69,2 ± 14,2 years, with the majority of men (63%). No statisticallysignificant differences were found in the incidence of OHCA regarding analysed weather conditions. Inthe subgroup of men, the incidence of OHCA was higher on days with the atmospheric pressure increasebetween consecutive days (p = 0.028) with the highest prevalence on days with pressure increase lessthan 5 hPa (p = 0.026). In a group of patients ≤ 65 years old the incidence of OHCA was the highest ondays with day-to-day pressure change between 0.1 and 4.9 hPa (p = 0.025). Conclusions: Among many weather parameters, only a few of them might be significant for the occurrenceof OHCA in the moderate climate of Poland. In the population of men and patients ≤ 65 years old theincidence of OHCA may be influenced by atmospheric pressure changes

Off-target effects of glycoprotein IIb/IIIa receptor inhibitors

Soon after identification of the platelet membrane glycoprotein (GP) IIb/IIIa, it has become a target of antiplatelet therapy. There are 3 intravenous GP IIb/IIIa receptor inhibitors, namely— eptifibatide, tirofiban and abciximab, used in the contemporary clinical practice, particularly in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). The aim of the current review is to summarize available knowledge concerning off-target effects of GP IIb/IIIa receptor inhibitors. All 3 drugs have similar antithrombotic properties, but differ with respect to pharmacodynamics, pharmacokinetics and off-target effects. Eptifibatide and tirofiban are highly specific GP IIb/IIIa receptor inhibitors, while abciximab is unselectiveand cross-reacts with integrin avb3 — a vitronectin receptor and leukocyte-associatedi ntegrin Mac-1. As a result of these interactions, abciximab seems to reduce the development of clinical restenosis, decrease infarct size, inhibit adhesion of monocytes to medical steel and modulate the inflammatory response. Intracoronary administration of abciximab provides higher drug concentration in the target area, increasing dose-dependent interactions with other integrins. Off-target effects of small molecule GP IIb/IIIa receptor inhibitors (i.e. eptifibatide and tirofiban) are predominantly connected with their suppressive influence on the inflammatory response. All in all, although GP IIb/IIIa receptor inhibitors are not recommended as a routine therapy during PCI, their antiplatelet properties and potential off-target effects may bebeneficial in certain subsets of patients

Mild therapeutic hypothermia for patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention (UNICORN). The design and rationale for the prospective, observational, multicenter study

Introduction. Cardiac arrest constitutes the most frequent reason for sudden death in developed countries. Out-of-hospital cardiac arrest (OHCA) survivors are at high risk of death or neurologic deficits. The existing data regarding effectiveness and safety of mild therapeutic hypothermia (MTH) for treatment of OHCA survivors are inconsistent and ambiguous. Moreover, a uniform protocol of treatment by means of MTH is lacking. Methods. The UNICORN study is a phase IV, prospective, international, multi-centre, observational study designed to assess the effectiveness of MTH in patients after OHCA with shockable rhythm presenting with acute coronary syndrome (ACS). The trial is expected to include up to 500 patients. Depending on the availability of MTH in each study centre, besides the routine treatment of ACS in OHCA survivors, patients will either undergo MTH according to a uniform protocol or will not undergo MTH (250 patients per group). The primary end-point of the study is all cause mortality at 180 days after enrolment. Secondary end-points include: neurological outcome at discharge, stent thrombosis at 30 days, bleeding according to the BARC criteria, infectious complications at 180 days, and rhythm and conduction disorders at 180 days. Ethics and dissemination. The study received approval from the Local Ethics Committee to conduct the study (Komisja Bioetyczna Uniwersytetu Mikołaja Kopernika w Toruniu przy Collegium Medicum im. Ludwika Rydygiera w Bydgoszczy; study approval reference number KB 615/2015). The study results will be disseminated through conference presentations and publications in peer-reviewed journals. Trial registration. ClinicalTrials.gov identifier: NCT02611934 (18 November 2015).

The impact of metabolic syndrome on the antiplatelet effect of clopidogrel and aspirin in patients with acute coronary syndrome

Aim. The aim of this study was to evaluate the impact of metabolic syndrome and features clustering in this syndrome on the antiplatelet effect of clopidogrel and aspirin in patients with myocardial infarction.Material and methods. The study population comprised 186 consecutive patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Measurements of ADP induced platelet aggregation (ADP-PA) and arachidonic acid induced platelet aggregation (AA-PA) were performed using impedance aggregometry with a Multiplate Analyser. The following factors were analysed as potential determinants of responsiveness to clopidogrel and to aspirin: diagnosed metabolic syndrome, diabetes, hypertension, abdominal obesity, body mass index (BMI), and serum concentrations of triglycerides, HDL-cholesterol and high sensitivity C-reactive protein (hsCRP).Results. The ADP-PA was significantly higher in patients with metabolic syndrome and with diabetes.The AA-PA was significantly higher in subjects with increased levels of hsCRP and in subjects with BMI &gt; 25 kg/m2. The hsCRP was found to be the only independent factor influencing APD-PA (p=0.034). Serum concentrations of hsCRP, HDL-cholesterol and abdominal obesity were independent factors influencing AA-PA (p=0.000004).Conclusion. Metabolic syndrome, diabetes mellitus, obesity and increased hsCRP are determinants of low responsiveness to aspirin and clopidogrel in patients with ACS treated with PCI

ACS network-based implementation of therapeutic hypothermia for the treatment of comatose out-of-hospital cardiac arrest survivors improves clinical outcomes: the first European experience

Background: There is a paucity of data regarding clinical outcomes associated with the integration of a mild therapeutic hypothermia (MTH) protocol into a regional network dedicated to treatment of patients with acute coronary syndromes (ACS). Additionally, a recent report suggests that the neurological benefits of MTH therapy in interventionally managed ACS patients resuscitated from out-of-hospital cardiac arrest (OHCA) may be potentially offset by the catastrophic occurrence of stent thrombosis. The goal of this study was to share our experience with the implementation of an MTH program using a previously established ACS network in consecutive comatose OHCA survivors undergoing interventional management due to an initial diagnosis of ACS and to assess the clinical effectiveness and safety of MTH. Methods: We conducted a retrospective historically controlled single centre study. Hospital survival with a favourable neurological outcome (Cerebral Performance Category of 1 or 2) and all-cause in-hospital mortality were the primary and secondary efficacy end points, respectively. Occurrence of definite stent thrombosis was the primary safety end point while the development of pneumonia, presence of positive blood cultures, occurrence of probable stent thrombosis, any bleeding complications, need for red blood cell transfusion and presence of rhythm and conductions disorders during hospitalisation constituted secondary safety end points. Results: Comatose OHCA survivors (n = 32) were referred to our Department based on ECG recording transmissions and/ or phone consultations or admitted from the Emergency Department. Compared with controls (n = 33), they were significantly more likely to be discharged from hospital with a favourable neurological outcome (59 vs. 27%; p < 0.05; number needed to treat [NNT] = 3.11) and experienced lower all-cause in-hospital mortality (13 vs. 55%; p < 0.05; NNT = 2.38). Rates of all safety end points were similar in patients treated with and without MTH. Conclusions: Our study indicates that a regional system of care for OHCA survivors may be successfully implemented based on an ACS network, leading to an improvement in neurological status and to a reduction of in-hospitalmortality in patients treated with MTH, without any excess of complications. However, our findings should be verified in large, prospective trials