November 29, 2022

Dr. Saraschandra Vallabhajosyula, an Interventional and Critical Care Cardiologist at Wake Forest University, in Winston-Salem, NC, shares results of his study appearing in the June 2022 issue of Mayo Clinic Proceedings, where he evaluated the outcomes, safety and efficacy of dual antiplatelet therapy with newer P2Y12 inhibitors compared to clopidogrel in acute myocardial infarction complicated by cardiac arrest or cardiogenic shock, He found that newer P2Y12 inhibitors were associated with lower rates of early and one-year mortality in patients experiencing acute myocardial infarction with cardiac arrest or cardiogenic shock and receiving dual antiplatelet therapy, when compared to clopidogrel. Data on major bleeding and stent thrombosis were inconclusive. Available at:

Our study is looking at the role of newer p2y12 inhibitors uh so prasa prostaglandical are in comparing them to clopidogrel which has been the standard of care for dual antiplatelet therapy in patients with acute mi that is complicated by cardiac arrest and ketogenic shock my name is dr saras chandra wala ba josela i’m an interventional and a critical care

Cardiologist at wake forest university in north carolina i’m here to talk about a recent study that was accepted in mayo clinic proceedings our study is entitled newer p2y12 inhibitors versus clopidogrel in acute myocardial function with cardiac arrest or cardiogenic shock a systematic review and meta-analysis this study is slated to be published in june 2022

Edition of the mayo clinic proceedings uh first of all my gratitude to my clinic proceedings for giving me this opportunity to speak and to the journal itself are accepting our manuscript we’re really excited about this paper uh so as you may well know acute mi is unfortunately very prevalent in our society continues to be a leading cause for cardiovascular

Mortality and morbidity through multiple techniques primarily with revascularization using primary pci we’ve been able to significantly change the trajectory of these patients and offer them good outcomes but high-risk conditions in patients with acute mi such as cardiogenic shock and cardiac arrest have close to 50 mortality despite all the strong medical

Therapy and revascularization techniques that we have at our disposal so it’s in these patients that we need to identify uh improved signals to how to better care for these patients off late in patients with acute mi there has been a lot of data that’s come out that shows newer p2y12 inhibitors which are used to provide dual antiplatelet therapy such as procedural

And ticagrelor have been superior to the gold standard of clopidogrel which was the first p2i12 inhibitor so obviously the next logical question to ask is how do these medications fair in patients with cardiogenic shock and cardiac arrest which are high risk conditions these two disease states are unique in that they have multi-system morbidity in patients

Like rmi they have decreased gi absorption because of gut ischemia often these patients have respiratory failure and need to be mechanically ventilated and so they cannot do the suck and swallow of the pills as efficiently as somebody who is not intubated these patients have hepatic dysfunction have renal dysfunction all of which in a bit the excretion and the

Bioavailability of all these medications so this constitutes a very specific subset also you have to understand that these patients are often on things like continuous renal replacement therapy on mechanical circulatory support either with impeller ibp or an external circuit such as an ecmo and therefore their pharmacokinetics is significantly affected by just

The extension of the body into these circuits or the circulation into these circuits so therefore uh we studied this in a meta-analytic fashion we had close to 1100 patients across the seven studies that we put together in this meta-analysis and we interestingly a lot of them were retrospective in nature only one was a randomized trial which is typical for

The data that comes of the space unlike most of cardiology where we have tens of thousands of patients randomized into carefully selected cohorts uh ketogenic shock and cardiac arrest are limited by recruitment because of the acuity of the status and because of how uncommon it is oftentimes we don’t have the large sample sizes that we get in the rest of general

Cardiology so um the major headline findings of our study were that we found a improved mortality at short term so short term is defined in our study was defined as uh in hospital 28-day or uh 30-day depending on how the studies uh projected these data because we were obviously amalgamating existing studies and we showed an improved mortality with prosecutorial

Anti-calgary as compared to clopidogrel this is certainly consistent with the signal across uh general acura my population both stemi and non-stemi and it’s very encouraging it uh also these newer p2 vital inhibitors have been associated with higher bleeding and higher rates of complications which we did not show in our study which is also a positive signal the

Lack of differences in bleeding and we did not have any differences in strength thrombosis which again is a testament to the evolution of stent technologies over time so this is a definitely an important study in terms of what it adds to the literature in this space for me as an interventional cardiologist and a critical care cardiologist i transact in this

Space all the time so i find it very relevant to my practice and has definitely influenced my practice and i hope that it adds to the practice of other people obviously uh the limitations of our study this being a meta-analysis is limited by the quality of the data that is available at our disposal so if six out of seven studies were retrospective they come

With the associated biases that they come in a retrospective study um obviously um we need more powered adequately powered carefully designed long-term analyses of these patients uh in a subgroup where we included three studies that looked at long-term mortality or one-year mortality they had a neutral signal also it’s important to understand that uh cardiac

Arrest and cardiogenic shock though similar are not the same people behave differently in cardiac arrest than they do in cardiogenic shock sometimes these disease states overlap sometimes they don’t um our signal was largely driven by cardiogenic shock because that’s where the largest mortality and the largest number of studies were so maybe specific studies

Relating to cardiac arrest or even more enriched studies in the space of ketogenic shock are probably needed to help understand uh this issue in its entirety so that we can provide appropriate personalized care for our patients at their bedside thank you for your attention and my email is available on the study details please feel free to reach out should you have

Additional questions for me or my team thank you we hope you found this presentation from the content of our website valuable our journal’s mission is to promote the best interests of patients by advancing the knowledge and professionalism of the physician community if you are interested in more information about us our home page is www.mayoclinicproceedings.org

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Transcribed from video
P2Y12 Inhibitors vs Clopidogrel in Acute MI With Cardiac Arrest or Cardiogenic Shock By Mayo Proceedings