京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22353号 / 医博第4594号 / 新制||医||1042(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 佐藤 俊哉, 教授 湊谷 謙司, 教授 福原 俊一 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Healthcare providers often are faced with the challenge of determining an appropriate length of dual antiplatelet therapy (DAPT) for patients who have had percutaneous coronary intervention and stent placement. This is an especially challenging clinical decision for patients with drug-eluting stents, as several studies show different results when assessing risk and benefit.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18868号 / 医博第3979号 / 新制||医||1008(附属図書館) / 31819 / 京都大学大学院医学研究科医学専攻 / (主査)教授 横出 正之, 教授 坂田 隆造, 教授 川村 孝 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Introduction Prior to percutaneous coronary intervention (PCI) guidelines recommend that patients with ST- elevation myocardial infarction (STEMI) receive dual antiplatelet therapy (DAPT) consisting of P2Y12 inhibition and acetylsalicylic acid (aspirin). However, in rare occasions, patients admitted with STEMI as preliminary diagnosis require acute thoracic surgery and oral P2Y12 inhibitors increases the bleeding risk over several hours. Cangrelor is an intravenous reversible P2Y12 antagonist with normal platelet function returning within 60 minutes and might therefore be an attractive alternative to oral P2Y12 inhibition.Aim Firstly, to quantify P2Y12 pre-treatment with ticagrelor in patients undergoing acute thoracic surgery and the mortality and morbidity rate associated with DAPT prior to surgery. Secondly, to estimate cost-benefit differences between cangrelor and ticagrelor pre-treatment.Material and Methods A descriptive cohort study using retrospective data. The inclusion criteria were patients undergoing acute thoracic surgery (≤ 24 hours) between January 2015 and December 2017, in the catchment area of Örebro University Hospital. Patients were stratified into groups depending on whether they had received pre-treatment with DAPT or not before surgery. Statistical analyses were made in SPSS and Excel.Results A total of 50 patients were included. 8 patients received DAPT before surgery. There was no mortality in patients receiving DAPT but TIMI major bleeding was more frequent compared to the group with no pre-treatment. The DAPT group required numerically more units of platelets and plasma, however the result was not significant. Direct treatment costs for ticagrelor was 20.14 SEK (the dosage is 2 tablets) and cangrelor was 3 059 SEK.Conclusions DAPT pre-treatment with ticagrelor was not associated with increased mortality but TIMI major bleeding was more frequent compared to the group with no pre-treatment. Direct treatment costs with cangrelor was higher compared to ticagrelor treatment. Further studies, with larger study samples, are needed to investigate complications associated with P2Y12 pre-treatment in patients undergoing acute thoracic surgery.

Background: Dual antiplatelet therapy (DAPT) is a mainstay treatment for hospital survivors of an acute myocardial infarction (AMI). However, there are extremely limited data on the prescribing patterns of DAPT among patients hospitalized with AMI. Objective: To examine decade-long trends (2001-2011) in the use of DAPT versus antiplatelet monotherapy and patient characteristics associated with DAPT use. Methods: The study population consisted of 2,389 adults hospitalized with an initial AMI at all 11 central Massachusetts medical centers on a biennial basis between 2001 and 2011. DAPT was defined as the discharge use of aspirin plus either clopidogrel or prasugrel. Logistic regression analysis was used to identify patient characteristics associated with DAPT use. Results: The average age of the study population was 65 years, and 69% of them were discharged on DAPT. The use of DAPT at the time of hospital discharge increased from 49% in 2001 to 74% in 2011; this increasing trend was seen across all age groups, both sexes, types of AMI, and in those who underwent a PCI. After multivariable adjustment, older age was the only factor associated with lower odds of receiving DAPT, while being male, receiving additional evidence-based cardioprotective therapy and undergoing cardiac stenting were associated with higher odds of receiving DAPT. Conclusions: Between 2001 and 2011, the use of DAPT increased markedly among patients hospitalized with AMI. However, a significant proportion of patients were not discharged on this therapy. Greater awareness is needed to incorporate DAPT into the management of patients with AMI.