Individualizing Duration of Dual Antiplatelet Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 21 Linguagem: Inglês
10.1161/circulationaha.115.021158
ISSN1524-4539
AutoresAkshay Bagai, Deepak L. Bhatt, John W. Eikelboom, G.B. John Mancini, Eric A. Cohen, Ram Vijayaraghavan, Asim N. Cheema, Jacob A. Udell, Joel Niznick, Jean‐François Tanguay, Subodh Verma, Shamir R. Mehta,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculationVol. 133, No. 21Individualizing Duration of Dual Antiplatelet Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBIndividualizing Duration of Dual Antiplatelet Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention Akshay Bagai, MD, MHS Deepak L. Bhatt, MD, MPH John W. Eikelboom, MBBS G.B. John Mancini, MD Eric A. Cohen, MD Ram Vijayaraghavan, MD Asim N. Cheema, MD, PhD Jacob A. Udell, MD, MPH Joel Niznick, MD Jean-Francois Tanguay, MD Subodh Verma, and MD, PhD Shamir R. MehtaMD, MSc Akshay BagaiAkshay Bagai From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Deepak L. BhattDeepak L. Bhatt From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , John W. EikelboomJohn W. Eikelboom From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , G.B. John ManciniG.B. John Mancini From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Eric A. CohenEric A. Cohen From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Ram VijayaraghavanRam Vijayaraghavan From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Asim N. CheemaAsim N. Cheema From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Jacob A. UdellJacob A. Udell From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Joel NiznickJoel Niznick From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Jean-Francois TanguayJean-Francois Tanguay From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , Subodh VermaSubodh Verma From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). , and Shamir R. MehtaShamir R. Mehta From Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, ON, Canada (A.B., A.N.C.); Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.,); Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (J.W.E., S.R.M.); Vancouver Hospital, University of British Columbia, Vancouver, Canada (G.B.J.M.); Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.A.C.); Division of Cardiology, Rouge Valley Health System, Scarborough, ON, Canada (R.V.); Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, ON, Canada (J.A.U.); University of Ottawa, ON, Canada (J.N.); Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); and Division of Cardiac Surgery, Keenen Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada (S.V.). Originally published24 May 2016https://doi.org/10.1161/CIRCULATIONAHA.115.021158Circulation. 2016;133:2094–2098IntroductionClinical Presentation 1: A 68-year-old man with a history of treated dyslipidemia was admitted with non–ST-segment–elevation myocardial infarction (MI). Coronary angiography showed a thrombotic subtotal occlusion of the proximal dominant right coronary artery and 50% stenosis in the mid left anterior descending and first obtuse marginal arteries. He underwent percutaneous coronary intervention (PCI) to the proximal right coronary artery with a second-generation drug-eluting stent (DES). How do you decide on the duration of dual antiplatelet therapy (DAPT) in this individual?Clinical Presentation 2: An 81-year-old woman weighing 52 kg with a history of hypertension and gastroesophageal reflux disease presented with Canadian Cardiovascular Society class III stable angina. Myocardial perfusion imaging showed a moderate area of anterior ischemia. At coronary angiography, she had an eccentric 95% calcified lesion in the mid left anterior descending artery. She also had mild disease (≈30% stenosis) in the proximal right coronary and mid left circumflex coronary arteries. The left anterior descending artery was stented with a second-generation DES. How do you apply the evidence for DAPT in this patient?BackgroundDAPT with aspirin and a P2Y12 receptor inhibitor is an essential component of the treatment of patients with acute coronary syndromes (ACS) and those undergoing PCI. DAPT after ACS reduces death and MI compared with aspirin alone, both in patients treated with PCI and in those who are managed conservatively.1–3 After elective PCI for stable coronary disease, DAPT reduces ischemic events and stent thrombosis (ST).4,5 However, these benefits come at the cost of increased risk of bleeding,6 raising the question about how to best balance efficacy and safety in determining the duration of DAPT.Duration of DAPT After ACSWhat Is the Evidence?Current treatment guidelines recommend 1 year of DAPT after ACS.7–9 This recommendation is based largely on the duration of treatment in the pivotal P2Y12 receptor inhibitor studies.1,3,10 Accumulating data support extending DAPT beyond 1 year after MI. In the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial,11 among patients with prior MI, adding clopidogrel to aspirin was associated with a reduction in cardiovascular death, MI, or stroke compared with treatment with aspirin alone.12 The DAPT trial demonstrated that in patients treated with PCI, compared with 12 months of treatment, extending DAPT for 30 months with clopidogrel or prasugrel reduced ST by two thirds and the composite of death, MI, or stroke by about one third, with ≈2.5-fold greater major bleeding.13 The ischemic benefit with extended DAPT was larger when PCI was performed in the setting of MI rather than stable angina.5 A second trial, Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin–Thrombolysis in Myocardial Infarction 54 (PEGASUS-TIMI 54), showed a reduction in ischemic events with ticagrelor in high-risk patients with a prior MI 1 to 3 years before enrollment.14 Treatment up to 3 years with ticagrelor at a dose of 90 or 60 mg twice daily resulted in a 1.2% absolute or 15% relative risk reduction in the composite of cardiovascular death, MI, or stroke compared with placebo. This benefit also came at the cost of more major bleeding (but not fatal or intracranial bleeding), which was ≈2.5-fold greater with ticagrelor. The overall tolerability of ticagrelor seemed more favorable at the lower dose of 60 mg twice daily compared with the higher dose of 90 mg twice daily.In a meta-analysis of >33 000 patients stabilized after ACS, extended DAPT beyond 1 year resulted in an absolute risk reduction of 1.1% in the composite of cardiovascular death, MI, or stroke (number needed to treat, 91) over a mean follow-up of 31 months at a cost of a 0.8% absolute increase in major bleeding (number needed to harm, 132; Figure 1).15 Importantly, significant reductions in each component of the composite were observed, including cardiovascular death, and intracranial hemorrhage and fatal bleeding events were infrequent and not significantly increased. The studies typically consisted of predominantly biomarker-positive patients with ACS and excluded patients at high risk of bleeding. Therefore, the results may not be generalizable to all patients with ACS. Patients with ACS who have tolerated DAPT without bleeding and are not at high risk of bleeding appear to be most suitable for extended therapy beyond 1 year.Download figureDownload PowerPointFigure 1. Risk of individual cardiovascular and bleeding end points in a comparison of extended dual antiplatelet therapy (DAPT) with aspirin alone in patients with myocardial infarction. CI indicates confidence interval. Reproduced with permission from Udell et al.15 Copyright © 2016 European Society of Cardiology.Recommendations for Individualizing Duration of DAPT After ACSA pragmatic approach that individualizes the duration of DAPT after ACS on the basis of the balance of bleeding and ischemic risk within the context of the available evidence is suggested.Except for patients at very high bleeding risk (eg, prior intracranial hemorrhage, recent gastrointestinal bleeding, or concomitant anticoagulation use), at least 1 year of treatment with DAPT should remain the standard.Among those at very high bleeding risk or among those who experience significant bleeding while on DAPT, a shorter duration of 75 years, prior stroke/transient ischemic attack, low body weight <60 kg, renal dysfunction on dialysis, liver synthetic dysfunction), 1 year of DAPT is sufficient.In all others, extended DAPT beyond 1 year is advised, particularly among those with clinical (eg, diabetes mellitus, peripheral artery disease, additional prior cardiovascular event, prior coronary revascularization) or angiographic (eg, left main stenting, bifurcation stenting) features associated with high ischemic risk. A dose of ticagrelor 60 mg twice daily or clopidogrel 75 mg daily is recommended beyond 1 year.An ongoing assessment of bleeding and ischemic risk should be performed at least annually to determine whether DAPT should be continued.Duration of DAPT After Second-Generation DES Implantation for Stable Coronary DiseaseWhat Is the Evidence?The recommended duration for DAPT after implantation of a DES was extended to 1 year after recognition of late ST with the first-generation devices. Lower risk of late ST with the current second-generation DES16 has been the basis for the reconsideration of abbreviating the duration of DAPT after PCI. Recently, several randomized, controlled studies have shown reduced bleeding rates with no increase in ischemic events, including ST, with a shortened duration of DAPT 31 000 patients also found an increase in noncardiovascular mortality with extended DAPT, which was not offset by benefit in cardiac mortality.20 Although the definitive mechanisms of the greater risk of noncardiovascular mortality remain unclear, greater propensity to bleeding on DAPT might increase mortality in patients who have trauma or in whom cancer develops. These results do not favor routinely extending DAPT beyond 12 months in non-ACS patients treated with current second-generation DES. Although clopidogrel remains the currently recommended P2Y12 receptor inhibitor in DAPT after PCI in non-ACS patients, a number of studies are examining the effectiveness of alternate P2Y12 receptor inhibitors with varying durations of DAPT.Recommendations for Individualizing Duration of DAPT After Coronary Stenting in a Non-ACS Stable SettingExcept for those at high bleeding risk, at least 6 months of DAPT is recommended.Among those at high bleeding risk, a shorter duration of DAPT (eg, 3 months) is recommended, with a minimum treatment duration of 1 month.Extending DAPT beyond 12 months might be considered for patients not at high risk of bleeding with high-risk clinical or angiographic features.ResolutionThe first patient with non–ST-segment–elevation MI treated with a single contemporary second-generation DES is not at increased risk for bleeding. Therefore, we recommended treatment with aspirin and ticagrelor 90 mg twice for the first year. If there is no evidence of significant bleeding, DAPT should be continued after the first year with ticagrelor at a reduced dose of 60 mg twice daily. Clopidogrel 75 mg daily is a reasonable alternative to ticagrelor if there are side effects or barriers to long-term adherence such as cost. Bleeding and ischemic risk should be assessed at least annually.The second patient with stable ischemic heart disease with a single-vessel focal discrete lesion who was treated with a contemporary second-generation DES is at higher-than-average bleeding risk because of her older age and low body weight. Because her ischemic risk is not higher than average and her bleeding risk is relatively high, we recommended treating her with aspirin and clopidogrel for 3 to 6 months.DisclosuresDr Bagai has received speaker's honoraria from AstraZeneca. Dr Bhatt discloses the following relationships: Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; Board of Directors: Boston VA Research Institute and Society of Cardiovascular Patient Care; chair: American Heart Association Quality Oversight Committee; Data Monitoring Committee: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; honoraria: American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org), Belvoir Publications (editor in chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (CME steering committees); other: Clinical Cardiology (deputy editor); research funding: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; royalties: Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); site coinvestigator: Biotronik, Boston Scientific, and St. Jude Medical; trustee: American College of Cardiology; and unfunded research: FlowCo, PLx Pharma, and Takeda. Dr Eikelboom has received honoraria and research support from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly Inc, Janssen, Pfizer, and Sanofi Aventis. Dr Mancini has received honoraria from AstraZeneca. Dr Cohen discloses consulting relationships with AstraZeneca, Eli Lilly Inc, Amgen, Medtronic, and Abbott Vascular; research support from AstraZeneca, Medtronic, and Boston Scientific; and speaking honoraria from AstraZeneca and Abbott Vascular. Dr Vijayaraghavan has received honoraria from AstraZeneca and educational support from Pfizer, Bristol-Myers Squibb, and St. Jude Medical. Dr Tanguay has received research support from Abbott Vascular, AstraZeneca, Eli Lilly Inc, GlaxoSmithKline, Ikeria, and Roche, as well as speaking or consulting honorarium from Abbott Vascular, Actelion, AstraZeneca, Bayer, and Eli Lilly Inc. Dr Verma has received honoraria or grant support from AstraZeneca, Bayer, BI, Lilly, Pfizer, Merck, Novartis, Amgen, Sorin, Abbott, and Jansen. Dr Mehta has received research grants from AstraZeneca and Boston Scientific. Drs Cheema and Udell report no conflicts.FootnotesCorrespondence to Shamir R. Mehta, MD, MSc, Hamilton Health Sciences, General Division, David Braley CVSRI Bldg, C3-11A, 237 Barton St E, Hamilton, ON, Canada, L8L 2X2. E-mail [email protected]; or Subodh Verma, MD, PhD, Division of Cardiac Surgery, St. Michael's Hospital, 30 Bond St, Toronto, ON, Canada M5B 1W8. E-mail [email protected]References1. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.N Engl J Med. 2001; 345:494–502. doi: 10.1056/NEJMoa010746.CrossrefMedlineGoogle Scholar2. 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May 24, 2016Vol 133, Issue 21Article InformationMetrics Download: 342 © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.021158PMID: 27217435 Originally publishedMay 24, 2016 PDF download SubjectsTreatmentPercutaneous Coronary InterventionAcute Coronary Syndromes
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