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Studies have linked on-treatment platelet reactivity (PR) to adverse clinical outcomes. Because new P2Y12 inhibitors (prasugrel and ticagrelor) have been predominantly tested against clopidogrel, data on pharmacodynamic comparisons between these 2 drugs are scarce. We compared ticagrelor with prasugrel in a network meta-analysis. PubMed, Cochrane, and EMBASE were searched for studies assessing PR in patients with coronary artery disease treated with ticagrelor or prasugrel. All studies using prasugrel and/or ticagrelor providing platelet function measurement data using VerifyNow P2Y12 reaction units (PRUs), platelet reactivity index (PRI) vasodilator-stimulated phosphoprotein phosphorylation, or maximal platelet aggregation (MPA) by light transmission aggregometry were considered eligible. Mixed treatment comparison models directly compared ticagrelor and prasugrel and indirectly compared them using clopidogrel as a comparator with data presented as mean difference (95% confidence interval). Data were extracted from 29 studies, including 5,395 patients. Compared with clopidogrel 75 mg, both prasugrel 10 mg and ticagrelor 90 mg twice daily were associated with lower PRU (mean difference -117 [-134.1, -100.5] and -159.7 [-182.6, -136.6], respectively), a lower PRI (-24.2 [-28.2, -20.3] and -33.6 [-39.9, -27.6], respectively), and lower MPA (-11.8 [-17, -6.3] and -20.7 [-28.5, -12.8], respectively). Similar results were obtained with clopidogrel 150 mg. Ticagrelor 90 mg twice daily was associated with lower PRU (-42.5 [-62.9, -21.9]), lower PRI (-9.3 [-15.6, -3.5]), and lower MPA (-8.9 [-16.4, -1.2]) compared with prasugrel 10 mg. In conclusion, our meta-analysis suggests that ticagrelor achieved significantly lower on-treatment PR compared with prasugrel, with both being superior to clopidogrel standard or high dose. [ABSTRACT FROM AUTHOR]

Patients with atrial fibrillation (AF) are at increased cardiovascular risk. The CHA 2 DS 2 -VASc score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke, vascular disease, age 65 to 74 years, female gender) has been used to predict thromboembolic risk in patients with nonvalvular AF. We aimed to evaluate the association between the CHA 2 DS 2 -VASc score and the risk of acute myocardial infarction (AMI) and all-cause mortality in patients with AF treated with direct oral anticoagulants (DOACs). The study was based on the Clalit Health Services database. Included were 21,129 patients with nonvalvular AF treated with DOACs. Patients were stratified into four groups according to the CHA 2 DS 2 -VASc score. 1-9 The primary end point was the occurrence of AMI and all-cause mortality. During 21,129 patient-years, there were 1,253 incidents (5.9%) of AMI. A higher CHA 2 DS 2 -VASc score was associated with a significantly increased risk of AMI (7.8, 14.9, 23.9, and 35.3 cases per 1,000 person-years, for patients with CHA 2 DS 2 -VASc score of 1 to 2, 3 to 4, 5 to 6, and 7 to 9, respectively, p <0.001). Each 1-point increase in the CHA 2 DS 2 -VASc score was associated with a 27% increased risk of AMI. A higher CHA 2 DS 2 -VASc score was also associated with a significantly increased ll-cause mortality rate (21.7, 60.2, 103.9, 162.6 cases per 1,000 person-years, for patients with CHA 2 DS 2 -VASc score of 1 to 2, 3 to 4, 5 to 6, 7 to 9, respectively, p <0.001). All associations remained statistically significant after a multivariate analysis. In conclusion, among patients with nonvalvular AF treated with DOACs, the CHA 2 DS 2 -VASc score was associated with increased risk of AMI and all-cause mortality., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

A significant proportion of patients with acute myocardial infarction (AMI) also present with clinical manifestations of inflammatory response, which may be confused with a concomitant infection. This leads to a dilemma regarding the empiric use of antibiotics. We explored if serum procalcitonin (PCT), which is known to be elevated in bacterial infections, may be utilized to rule-out bacterial infection in AMI patients. In this prospective, single center study, PCT was collected within 48 hours from AMI patients. Patients' demographic, clinical, and laboratory data were collected prospectively. Two experienced infectious diseases specialists blinded to the PCT results independently determined the presence of infection in every patient. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve were calculated to determine the accuracy of PCT, fever, white blood cell (WBC) count, and C-reactive protein (CRP) levels for the diagnosis of the infection. The analysis included 230 AMI patients (age 63.0 ± 13.0 years) of whom 36 (15.6%) had coexisting infections. The best cutoff for PCT as a differentiating marker between patients with and without coexisting infection was 0.09 ng/dl (sensitivity 94.4%, specificity 85.1%, area under the curve 0.94). PCT outperformed CRP, WBC, and fever for diagnosing infection. In conclusion, compared with CRP, fever, and WBC, serum PCT had a better performance in differentiating infected from noninfected AMI patients and thus should be considered as an adjunct test when facing the dilemma of initiating empiric antibiotic in AMI patient demonstrating inflammatory signs., (Copyright © 2018. Published by Elsevier Inc.)