Ignite Creation Date:
2024-05-06 @ 9:39 AM
Last Modification Date:
2024-10-26 @ 12:17 PM
Study NCT ID:
NCT03039205
Status:
COMPLETED
Last Update Posted:
2020-04-24
First Post:
2017-01-23
Brief Title:
Platelet Aggregation in Patients With Coronary Artery Disease and Kidney Dysfunction Taking Clopidogrel or Ticagrelor
Sponsor:
University of Sao Paulo
Organization:
University of Sao Paulo
Study Overview
Official Title:
Evaluation of Platelet Aggregation and Adenosine Levels in Patients With Coronary Artery Disease and Chronic Kidney Dysfunction Taking Dual Antiplatelet Therapy With Aspirin and Clopidogrel or Ticagrelor
Status:
COMPLETED
Status Verified Date:
2020-04
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
About 35 of patients hospitalized with Acute Coronary Syndromes ACS have some degree of renal dysfunction Chronic kidney disease CKD is not only associated to worse prognosis in ACS patients but leads also to an increased risk of bleeding which may importantly influence the risk-benefit ratio of antiplatelet therapy in this population The responsible mechanisms for increased rate of ischemic events in this population are not completely elucidated
Antiplatelet therapy is of paramount importance in the treatment of ACS but its benefit in CKD patients is not well established This population is often excluded or underrepresented in large clinical trials and the indication of antiplatelet therapy is often extrapolated from studies in patients with preserved renal function In recent meta-analysis Palmer et al sought to evaluate the benefits and risks of antiplatelet agents in patients with CKD and concluded that in patients with ACS or scheduled for angioplasty already taking aspirin the addition of clopidogrel or glycoprotein IIb IIIa inhibitors have little or no impact in reducing the incidence of myocardial infarction death or need for revascularization
In the PLATO trial ticagrelor a new reversible inhibitor of P2Y12 receptor with faster onset of action and greater platelet inhibition was compared to clopidogrel in patients with high risk ACS and was associated to a 16 risk reduction on the occurrence of death from vascular causes myocardial infarction or stroke In a pre-specified sub-analysis data from patients with CKD were compared to those obtained from the population with normal renal function and suggests that the benefit of ticagrelor may be even greater in patients with CKD Two hypotheses were considered to explain these results
1 Greater and more consistent platelet inhibition achieved with ticagrelor would be more effective in reducing ischemic events in this population at increased thrombotic risk
2 Pleiotropic effects of ticagrelor besides inhibition of the P2Y12 receptor Ticagrelor might be associated with an elevation in serum levels of adenosine This could improve myocardial perfusion through coronary vasodilation and this effect would be more pronounced in patients with renal dysfunction
This project aims to validate or not these hypotheses analyzing platelet aggregation and circulating adenosine levels in patients taking dual antiplatelet therapy with aspirin and clopidogrel or ticagrelor
Antiplatelet therapy is of paramount importance in the treatment of ACS but its benefit in CKD patients is not well established This population is often excluded or underrepresented in large clinical trials and the indication of antiplatelet therapy is often extrapolated from studies in patients with preserved renal function In recent meta-analysis Palmer et al sought to evaluate the benefits and risks of antiplatelet agents in patients with CKD and concluded that in patients with ACS or scheduled for angioplasty already taking aspirin the addition of clopidogrel or glycoprotein IIb IIIa inhibitors have little or no impact in reducing the incidence of myocardial infarction death or need for revascularization
In the PLATO trial ticagrelor a new reversible inhibitor of P2Y12 receptor with faster onset of action and greater platelet inhibition was compared to clopidogrel in patients with high risk ACS and was associated to a 16 risk reduction on the occurrence of death from vascular causes myocardial infarction or stroke In a pre-specified sub-analysis data from patients with CKD were compared to those obtained from the population with normal renal function and suggests that the benefit of ticagrelor may be even greater in patients with CKD Two hypotheses were considered to explain these results
1 Greater and more consistent platelet inhibition achieved with ticagrelor would be more effective in reducing ischemic events in this population at increased thrombotic risk
2 Pleiotropic effects of ticagrelor besides inhibition of the P2Y12 receptor Ticagrelor might be associated with an elevation in serum levels of adenosine This could improve myocardial perfusion through coronary vasodilation and this effect would be more pronounced in patients with renal dysfunction
This project aims to validate or not these hypotheses analyzing platelet aggregation and circulating adenosine levels in patients taking dual antiplatelet therapy with aspirin and clopidogrel or ticagrelor
Detailed Description:
Previous publications demonstrated that about 35 to 40 of patients hospitalized with Acute Coronary Syndromes ACS have some degree of renal dysfunction On the other hand chronic kidney disease CKD is not only associated to worse prognosis in ACS patients but leads also to an increased risk of bleeding which may importantly influence the risk-benefit ratio of antiplatelet therapy in this population Even at early stages CKD increases the risk of myocardial infarction and death among different spectra of ACS and the risk increase is directly proportional to the degree of renal dysfunction The responsible mechanisms for the increased rate of ischemic events in this population are not completely elucidated However accelerated atherosclerosis oxidative stress inflammation and increased platelet aggregation as well as underutilization of therapies such as antithrombotic agents and invasive procedures are some of the proposed mechanisms
Antiplatelet therapy is of paramount importance in the treatment of ACS but its benefit in CKD patients is not well established The fact that this population is often excluded or underrepresented in large clinical trials makes the indication for its use be very often extrapolated from studies in patients with preserved renal function
In recent meta-analysis Palmer et al sought to summarize the benefits and risks of antiplatelet agents in patients with CKD focusing on the occurrence of cardiovascular events including mortality and bleeding The results led them to conclude that 1 the evidence for the use of antiplatelet agents in patients with CKD and cardiovascular disease is of low quality 2 in patients with ACS or scheduled for angioplasty already taking acetylsalicylic acid ASA the addition of clopidogrel or glycoprotein IIb IIIa inhibitors have little or no impact in reducing the incidence of myocardial infarction death or need for revascularization and 3 there was a significant 40 increase in the incidence of major bleeding
In the PLATO trial - Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes - ticagrelor a new reversible inhibitor of the P2Y12 receptor with faster onset of action and greater platelet inhibition power was compared to clopidogrel in over 18000 patients with high risk ACS In this publication patients receiving ticagrelor had a 16 risk reduction on the occurrence of primary composite endpoint death from vascular causes myocardial infarction or stroke without significant increase in the incidence of major bleeding In a secondary outcome analysis it was found a significant reduction in mortality from vascular causes and mortality from any cause in patients treated with ticagrelor Among the high-risk criteria used in the selection of patients for this study a creatinine clearance 60 mlmin173 m2 was included
In a following article considering a pre-specified sub-analysis from the PLATO trial the results of 3237 patients who had this high-risk criterion were compared to those obtained for the population with normal renal function The developed comparisons suggest that the benefit of ticagrelor may be even greater in patients with CKD when considering the MDRD equation to estimate renal function the hazard-ratio HR for the primary outcome of the study was 071 for patients with renal impairment creatinine clearance 60 mlmin173m2 and 090 for those without renal dysfunction p 003 for interaction Furthermore the HRs for mortality were respectively 079 and 091 for patients with and without renal dysfunction P 002 for interaction Interestingly no significant difference between groups relatively to major bleeding was observed and the incidence of dyspnea was higher in the population without renal dysfunction
Two hypotheses were considered to explain these results The first suggests that a greater and more consistent platelet inhibition achieved with ticagrelor would be more effective in reducing ischemic events in this population at increased thrombotic risk The second hypothesis considers possible pleiotropic effects of ticagrelor besides the reversible inhibition of the P2Y12 receptor Ticagrelor might be associated with an elevation in serum levels of adenosine through the inhibition of its reuptake by erythrocytes and by increased release of adenosine triphosphate ATP from the same erythrocytes subsequently converted in adenosine by ecto-ATPases An increase in the concentrations of circulating adenosine could improve myocardial perfusion through coronary vasodilation and this effect would be more pronounced in patients with renal dysfunction
Thus this project aims to validate or not these hypotheses analyzing platelet aggregation and circulating adenosine levels in patients taking dual antiplatelet therapy with aspirin and clopidogrel or ticagrelor
Safety as this protocol was designed for a short-term duration we do not expect to have many adverse events AE An AE is any untoward medical occurrence in a participant that does not necessarily have a causal relationship with the study intervention An AE can therefore be any unfavorable or unintended sign including an abnormal laboratory finding symptom or disease temporally associated with the use of a medical treatment or procedure regardless of whether it is considered related to the medical treatment or procedure AEs will be reported as soon as possible
Serious adverse events SAE are defined as any untoward medical occurrence that meets any one of the following criteria
1 Results in death or is life-threatening at the time of the event
2 Requires inpatient hospitalization or prolongs a hospitalization
3 Results in a persistent or significant disabilityincapacity
4 Is a congenital anomalybirth defect in a participants offspring or
5 Is medically judged to be an important event that jeopardized the subject and for example required significant measures to avoid one of the above outcomes
SAEs will be reported within 24 hours of its information received The causality of SAEs their relationship to all study treatmentprocedures will be assessed by the investigators and the investigator is responsible for informing the local authorities and ethical committees of any serious adverse events as per local requirements
Antiplatelet therapy is of paramount importance in the treatment of ACS but its benefit in CKD patients is not well established The fact that this population is often excluded or underrepresented in large clinical trials makes the indication for its use be very often extrapolated from studies in patients with preserved renal function
In recent meta-analysis Palmer et al sought to summarize the benefits and risks of antiplatelet agents in patients with CKD focusing on the occurrence of cardiovascular events including mortality and bleeding The results led them to conclude that 1 the evidence for the use of antiplatelet agents in patients with CKD and cardiovascular disease is of low quality 2 in patients with ACS or scheduled for angioplasty already taking acetylsalicylic acid ASA the addition of clopidogrel or glycoprotein IIb IIIa inhibitors have little or no impact in reducing the incidence of myocardial infarction death or need for revascularization and 3 there was a significant 40 increase in the incidence of major bleeding
In the PLATO trial - Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes - ticagrelor a new reversible inhibitor of the P2Y12 receptor with faster onset of action and greater platelet inhibition power was compared to clopidogrel in over 18000 patients with high risk ACS In this publication patients receiving ticagrelor had a 16 risk reduction on the occurrence of primary composite endpoint death from vascular causes myocardial infarction or stroke without significant increase in the incidence of major bleeding In a secondary outcome analysis it was found a significant reduction in mortality from vascular causes and mortality from any cause in patients treated with ticagrelor Among the high-risk criteria used in the selection of patients for this study a creatinine clearance 60 mlmin173 m2 was included
In a following article considering a pre-specified sub-analysis from the PLATO trial the results of 3237 patients who had this high-risk criterion were compared to those obtained for the population with normal renal function The developed comparisons suggest that the benefit of ticagrelor may be even greater in patients with CKD when considering the MDRD equation to estimate renal function the hazard-ratio HR for the primary outcome of the study was 071 for patients with renal impairment creatinine clearance 60 mlmin173m2 and 090 for those without renal dysfunction p 003 for interaction Furthermore the HRs for mortality were respectively 079 and 091 for patients with and without renal dysfunction P 002 for interaction Interestingly no significant difference between groups relatively to major bleeding was observed and the incidence of dyspnea was higher in the population without renal dysfunction
Two hypotheses were considered to explain these results The first suggests that a greater and more consistent platelet inhibition achieved with ticagrelor would be more effective in reducing ischemic events in this population at increased thrombotic risk The second hypothesis considers possible pleiotropic effects of ticagrelor besides the reversible inhibition of the P2Y12 receptor Ticagrelor might be associated with an elevation in serum levels of adenosine through the inhibition of its reuptake by erythrocytes and by increased release of adenosine triphosphate ATP from the same erythrocytes subsequently converted in adenosine by ecto-ATPases An increase in the concentrations of circulating adenosine could improve myocardial perfusion through coronary vasodilation and this effect would be more pronounced in patients with renal dysfunction
Thus this project aims to validate or not these hypotheses analyzing platelet aggregation and circulating adenosine levels in patients taking dual antiplatelet therapy with aspirin and clopidogrel or ticagrelor
Safety as this protocol was designed for a short-term duration we do not expect to have many adverse events AE An AE is any untoward medical occurrence in a participant that does not necessarily have a causal relationship with the study intervention An AE can therefore be any unfavorable or unintended sign including an abnormal laboratory finding symptom or disease temporally associated with the use of a medical treatment or procedure regardless of whether it is considered related to the medical treatment or procedure AEs will be reported as soon as possible
Serious adverse events SAE are defined as any untoward medical occurrence that meets any one of the following criteria
1 Results in death or is life-threatening at the time of the event
2 Requires inpatient hospitalization or prolongs a hospitalization
3 Results in a persistent or significant disabilityincapacity
4 Is a congenital anomalybirth defect in a participants offspring or
5 Is medically judged to be an important event that jeopardized the subject and for example required significant measures to avoid one of the above outcomes
SAEs will be reported within 24 hours of its information received The causality of SAEs their relationship to all study treatmentprocedures will be assessed by the investigators and the investigator is responsible for informing the local authorities and ethical committees of any serious adverse events as per local requirements
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
False
Is a FDA Regulated Device?:
False
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None
Secondary IDs
| Secondary ID | Type | Domain | Link |
|---|---|---|---|
| 408614066 | OTHER | CAPPesq | None |