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. 2020 Feb 18;9(4):e014676.
doi: 10.1161/JAHA.119.014676. Epub 2020 Feb 11.

Clinical Implications of "Tailored" Antiplatelet Therapy in Patients With Chronic Total Occlusion

Free PMC article

Clinical Implications of "Tailored" Antiplatelet Therapy in Patients With Chronic Total Occlusion

Maria Grazia De Gregorio et al. J Am Heart Assoc. .
Free PMC article


Background Clopidogrel nonresponsiveness is a prognostic marker after percutaneous coronary intervention. Prasugrel and ticagrelor provide a better platelet inhibition and represent the first-line antiplatelet treatment in acute coronary syndrome. We sought to assess the prognostic impact of high platelet reactivity (HPR) and the potential clinical benefit of a "tailored" escalated or changed antiplatelet therapy in patients with chronic total occlusion. Methods and Results From Florence CTO-PCI (chronic total occlusion-percutaneous coronary intervention) registry, platelet function assessed by light transmission aggregometry, was available for 1101 patients. HPR was defined by adenosine diphosphate test ≥70% and optimal platelet reactivity by adenosine diphosphate test <70%. The endpoint of the study was long-term cardiac survival. Patients were stratified according to light transmission aggregometry results: optimal platelet reactivity (82%) and HPR (18%). Means for the adenosine diphosphate test were 44±16% versus 77±6%, respectively. Three-year survival was significantly higher in the optimal platelet reactivity group compared with HPR patients (95.3±0.8% versus 86.2±2.8%; P<0.001). With the availability of new P2Y12 inhibitors, a deeper platelet inhibition (46±17%) and similar survival to the optimal platelet reactivity group were achieved in patients with HPR on clopidogrel therapy after escalation. Conversely, HPR on clopidogrel therapy "not switched" was associated with cardiac mortality (hazard ratio 2.37; P=0.003) after multivariable adjustment. Conclusions HPR on treatment could be a modifiable prognostic marker by new antiaggregants providing a deeper platelet inhibition associated with clinical outcome improvement in complex chronic total occlusion patients. A "tailored" antiplatelet therapy, also driven by the entity of platelet inhibition, could be useful in these high risk setting patients.

Keywords: antiplatelet therapy; chronic total occlusion; platelet reactivity.


Figure 1
Figure 1
Flow‐chart of the study. CTO indicates chronic total occlusion; HPR, high platelet reactivity; LTA, light transmission aggregometry; OPR, optimal platelet reactivity; PCI, percutaneous coronary intervention.
Figure 2
Figure 2
Survival analysis according to platelet reactivity. A, Cardiac survival curves demonstrated a long‐term benefit in the OPR group compared with the HPR subgroup in which antiplatelet therapy was “not switched.” Conversely, after a “tailored” antiplatelet therapy by escalation and/or change, no more significant differences in survival curves were detected between the HPR “switched” subgroup and the OPR group. B, Survival analysis including discontinuation time of DAPT as censoring event together with death and loss to follow‐up in OPR and HPR “switched” groups. DAPT indicates dual antiplatelet therapy; HPR, high platelet reactivity; OPR, optimal platelet reactivity.

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