Impact of Chronic Antiplatelet Therapy on Infarct Size and Bleeding in Patients With Acute Myocardial Infarction

Background: Patients hospitalized with acute myocardial infarction (AMI) are often on prior single antiplatelet therapy (SAPT) or a dual antiplatelet therapy (DAPT). Whether chronic SAPT or DAPT is beneficial or associated with an increased risk in AMI is still controversial. Methods and Results: We prospectively enrolled 1718 consecutive patients with AMI (798 ST-segment elevation myocardial infarction and 920 non-ST-segment elevation myocardial infarction) who were divided according to their chronic APT (no APT, SAPT, or DAPT). The study primary end point was the infarct size, as estimated by troponin I peak. Incidence of major bleeding was also evaluated. Five hundred thirty-six (31%) patients were on chronic SAPT and 215 (13%) on DAPT. A graded increase in Global Registry of Acute Coronary Events (GRACE) and Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) risk scores was found going from patients without APT to those with DAPT, while a progressive smaller troponin I peak was observed with the increasing number of chronic antiplatelet agents (11.2 [interquartile range: 2-45] ng/mL, 6.6 [1-33] ng/mL, and 4.1 [1-24] ng/mL; P < .001 for trend). This result was maintained after adjustment for baseline ischemic risk profile (GRACE score) and other major confounders (P < .001). The incidence of bleeding was higher in patients on chronic APT than in those without APT (5.2% vs 2.4%; P = .002). However, when the bleeding risk was adjusted for the CRUSADE risk score, chronic SAPT (odds ratio [OR]: 1.40, 95% confidence interval [CI]: 0.77-2.53) and DAPT (OR: 0.70, 95% CI: 0.29-1.70) were not associated with an increased bleeding risk. Conclusion: In patients with AMI, chronic APT is associated with higher baseline ischemic and bleeding risks. Despite this and unexpectedly, they have a smaller infarct size and similar adjusted bleeding risk.

[1]  S. Pocock,et al.  Longer-term oral antiplatelet use in stable post-myocardial infarction patients: Insights from the long Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease (TIGRIS) observational study. , 2017, International journal of cardiology.

[2]  F. Carreras,et al.  Protective Effects of Ticagrelor on Myocardial Injury After Infarction , 2016, Circulation.

[3]  G. Stone,et al.  Pretreatment with aspirin in acute coronary syndromes: Lessons from the ACUITY and HORIZONS-AMI trials , 2016, European heart journal. Acute cardiovascular care.

[4]  G. Schaer,et al.  Duration of Dual Antiplatelet Therapy in Coronary Artery Disease: a Review Article , 2016, Current Atherosclerosis Reports.

[5]  D. Prabhakaran,et al.  Effect of prior clopidogrel use on outcomes in medically managed acute coronary syndrome patients , 2016, Heart.

[6]  M. Kofler,et al.  High-sensitivity troponin T for prediction of left ventricular function and infarct size one year following ST-elevation myocardial infarction. , 2016, International journal of cardiology.

[7]  D. Andreini,et al.  Myocardial Infarct Size in Patients on Long-Term Statin Therapy Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. , 2015, The American journal of cardiology.

[8]  A. Assinger,et al.  Aspirin and P2Y12 Inhibitors in platelet-mediated activation of neutrophils and monocytes , 2015, Thrombosis and Haemostasis.

[9]  J. Perez-polo,et al.  Ticagrelor Protects the Heart Against Reperfusion Injury and Improves Remodeling After Myocardial Infarction , 2015, Arteriosclerosis, thrombosis, and vascular biology.

[10]  A. Jaffe,et al.  2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. , 2014, Circulation.

[11]  Braunwald,et al.  Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. , 2014, The New England journal of medicine.

[12]  Deepak L. Bhatt,et al.  In-Hospital Switching Between Clopidogrel and Prasugrel Among Patients With Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention: Insights Into Contemporary Practice From the National Cardiovascular Data Registry , 2014, Circulation. Cardiovascular interventions.

[13]  C. Stefanadis,et al.  In-hospital switching of oral P2Y12 inhibitor treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention: prevalence, predictors and short-term outcome. , 2014, American heart journal.

[14]  Michael V. Cohen,et al.  Platelet P2Y12 Blockers Confer Direct Postconditioning-Like Protection in Reperfused Rabbit Hearts , 2013, Journal of cardiovascular pharmacology and therapeutics.

[15]  S. Steinhubl,et al.  Impact of chronic antiplatelet therapy before hospitalization on ischemic and bleeding events in invasively managed patients with acute coronary syndromes: the ACUITY trial , 2011, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[16]  R. Giugliano,et al.  Prior aspirin use and outcomes in acute coronary syndromes. , 2010, Journal of the American College of Cardiology.

[17]  R. Collins,et al.  Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials , 2009, The Lancet.

[18]  Sunil V. Rao,et al.  Baseline Risk of Major Bleeding in Non–ST-Segment–Elevation Myocardial Infarction: The CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Bleeding Score , 2009, Circulation.

[19]  J. J. Griffin,et al.  Predictors of infarct size after primary coronary angioplasty in acute myocardial infarction from pooled analysis from four contemporary trials. , 2007, The American journal of cardiology.

[20]  H. Krumholz,et al.  Prior aspirin use and outcomes in elderly patients hospitalized with acute myocardial infarction. , 2005, Journal of the American College of Cardiology.

[21]  Carlos Aguiar,et al.  TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. , 2005, European heart journal.

[22]  Sunil V. Rao,et al.  Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes , 2004 .

[23]  Sunil V. Rao,et al.  Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. , 2004, JAMA.

[24]  S. Callegari,et al.  Circadian distribution of acute myocardial infarction by anatomic location and coronary artery involvement. , 2004, The American journal of medicine.

[25]  J. Gore,et al.  Impact of aspirin on presentation and hospital outcomes in patients with acute coronary syndromes (The Global Registry of Acute Coronary Events [GRACE]). , 2002, The American journal of cardiology.

[26]  M. Cohen,et al.  Prior aspirin use in unstable angina predisposes to higher risk: the aspirin paradox. , 2001, International journal of cardiology.

[27]  E. Antman,et al.  The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. , 2000, JAMA.

[28]  R. Califf,et al.  Prior aspirin use predicts worse outcomes in patients with non-ST-elevation acute coronary syndromes. PURSUIT Investigators. Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy. , 1999, The American journal of cardiology.

[29]  E. Antman,et al.  Effects of prior aspirin and anti-ischemic therapy on outcome of patients with unstable angina. TIMI 7 Investigators. Thrombin Inhibition in Myocardial Ischemia. , 1998, The American journal of cardiology.

[30]  B. Gullberg,et al.  Clinical outcome of acute myocardial infarction in patients on treatment with beta-blockers or calcium antagonists. A study of 7,922 hospitalized first myocardial infarctions. , 1992, Cardiology.