Ticagrelor binds to human P2Y12 independently from ADP but antagonizes ADP-induced receptor signaling and platelet aggregation

Summary. Background: P2Y₁₂ plays an important role in regulating platelet aggregation and function. This receptor is the primary target of thienopyridine antiplatelet agents, the active metabolites of which bind irreversibly to the receptor, and of newer agents that can directly and reversibly modulate receptor activity. Objective: To characterize the receptor biology of the first reversibly binding oral P2Y₁₂ antagonist, ticagrelor (AZD6140), a member of the new cyclopentyltriazolopyrimidine (CPTP) class currently in phase III development. Methods: Ticagrelor displayed apparent non‐competitive or insurmountable antagonism of ADP‐induced aggregation in human washed platelets. This was investigated using competition binding against [³H]ADP, [³³P]2MeS‐ADP and the investigational CPTP compound [¹²⁵I]AZ11931285 at recombinant human P2Y₁₂. Functional receptor inhibition studies were performed using a GTPγS‐binding assay, and further binding studies were performed using membranes prepared from washed human platelets. Results: Radioligand‐binding studies demonstrated that ticagrelor binds potently and reversibly to human P2Y₁₂ with K_on and K_off of (1.1 ± 0.2) × 10^?4 nm ^?1 s^?1 and (8.7 ± 1.4) × 10^?4 s^?1, respectively. Ticagrelor does not displace [³H]ADP from the receptor (K_i > 10 μm ) but binds competitively with [³³P]2MeS‐ADP (K_i = 4.3 ± 1.3 nm ) and [¹²⁵I]AZ11931285 (K_i = 0.33 ± 0.04 nm ), and shows apparent non‐competitive inhibition of ADP‐induced signaling but competitive inhibition of 2MeS‐ADP‐induced signaling. Binding studies on membranes prepared from human washed platelets demonstrated similar non‐competitive binding for ADP and ticagrelor. Conclusions: These data indicate that P2Y₁₂ is targeted by ticagrelor via a mechanism that is non‐competitive with ADP, suggesting the existence of an independent receptor‐binding site for CPTPs.     

In the presence of strong P2Y12 receptor blockade,aspirin provides little additional inhibition of platelet aggregation

Summary. Background: Aspirin and antagonists of platelet ADP P2Y₁₂ receptors are often coprescribed for protection against thrombotic events. However, blockade of platelet P2Y₁₂ receptors can inhibit thromboxane A₂ (TXA₂)‐dependent pathways of platelet activation independently of aspirin. Objectives: To assess in vitro whether aspirin adds additional antiaggregatory effects to strong P2Y₁₂ receptor blockade. Methods: With the use of platelet‐rich plasma from healthy volunteers, determinations were made in 96‐well plates of platelet aggregation, TXA₂ production and ADP/ATP release caused by ADP, arachidonic acid, collagen, epinephrine, TRAP‐6 amide and U46619 (six concentrations of each) in the presence of prasugrel active metabolite (PAM; 0.1–10 μmol L^?1), aspirin (30 μmol L^?1), PAM + aspirin or vehicle. Results: PAM concentration‐dependently inhibited aggregation; for example, aggregation in response to all concentrations of ADP and U46619 was inhibited by ≥ 95% by PAM at > 3 μmol L^?1. In further tests of PAM (3 μmol L^?1), aspirin (30 μmol L^?1) and PAM + aspirin, aspirin generally failed to produce more inhibition than PAM or additional inhibition to that caused by PAM. The antiaggregatory effects of PAM were associated with reductions in the platelet release of both TXA₂ and ATP + ADP. Similar effects were found when either citrate or lepirudin were used as anticoagulants, and when traditional light transmission aggregometry was conducted at low stirring speeds. Conclusions: P2Y₁₂ receptors are critical to the generation of irreversible aggregation through the TXA₂‐dependent pathway. As a result, strong P2Y₁₂ receptor blockade alone causes inhibition of platelet aggregation that is little enhanced by aspirin. The clinical relevance of these observations remains to be determined.     

Randomized,double‐blind comparison of effects of abiciximab bolus only vs. on‐label regimen on ex vivo inhibition of platelet aggregation in responders to clopidogrel undergoing coronary stenting

Summary. Background: On top of aspirin, an abciximab bolus‐only regimen results in a 30% drop in platelet inhibition at 6 h as compared with the on‐label regimen. The concomitant administration of high loading dose clopidogrel, by bridging with abciximab bolus, may sustain suppression of platelet activity over time. Objectives: To investigate the non‐inferiority of abciximab bolus‐only and concomitant high loading dose clopidogrel vs. abciximab bolus + infusion with respect to the inhibition of platelet aggregation (IPA) as determined by light transmission aggregometry. Patients/Methods: Seventy‐three patients with non‐ST segment elevation acute coronary syndromes underwent double‐blind randomization to abciximab bolus followed by a 12‐h placebo infusion and concomitant 600‐mg clopidogrel vs. abciximab bolus + a 12‐h infusion and 300 mg of clopidogrel. IPA was determined by light transmission aggregometry throughout 24 h. Clopidogrel poor responsiveness was defined as ≥ 50% 5 μmol L^?1 ADP‐induced maximum platelet aggregation. Results: In clopidogrel responders (n = 68), IPA after 20 μmol L^?1 ADP at 4 h was 89% ± 13% in the bolus‐only arm vs. 92% ± 14% in the bolus + infusion arm (P = 0.011 for non‐inferiority). IPA after 5 or 20 μmol L^?1 ADP and 5 or 15 μmol L^?1 TRAP and the proportion of patients showing ≥ 80% IPA did not differ at any time point, irrespective of clopidogrel responsiveness status. Thirty‐day outcomes were similar, whereas hemoglobin (0.91 ± 0.8 vs. 0.5 ± 0.7 g dL^?1; P = 0.01) and platelet count mean drop (41.7 ± 57 vs. 18.6 ± 34 10⁹ L^?1; P = 0.042) were significantly reduced in the bolus‐only arm. Conclusions: Withholding abciximab post‐bolus infusion in patients receiving high loading dose clopidogrel does not impair platelet inhibition throughout 24 h, and has the potential to improve the safety profile of the drug at reduced costs.     

Earlier recovery of platelet function after discontinuation of treatment with ticagrelor compared with clopidogrel in patients with high antiplatelet responses

Summary. Background: The rate of recovery of platelet function after discontinuation of P2Y₁₂ inhibitors depends on the reversibility of the antiplatelet effect and the extent of the on‐treatment response. P2Y₁₂ inhibition increases the bleeding risk in patients requiring surgery. Objectives: To evaluate recovery of platelet function after discontinuation of ticagrelor vs. clopidogrel in stable coronary artery disease (CAD) patients with high levels of platelet inhibition (HPI) during the ONSET/OFFSET study. Methods: Patients received aspirin 75–100 mg per day and either ticagrelor 90 mg twice‐daily or clopidogrel 75 mg daily for 6 weeks. This subanalysis included patients with HPI after the last dose of maintenance therapy, defined as: inhibition of platelet aggregation (IPA) > 75% 4 h post‐dose (ADP 20 μm , final extent); < 120 P2Y₁₂ reaction units 8 h post‐dose (VerifyNow P2Y₁₂ assay); or platelet reactivity index < 50% 8 h post‐dose (VASP‐P assay). Results: IPA > 75% was observed in 39 out of 47 ticagrelor‐treated and 17 out of 44 clopidogrel‐treated patients. The rate of offset of IPA over 4–72 h was greater with ticagrelor (IPA %/hour slope: ?1.11 vs. ?0.67 for clopidogrel; P < 0.0001). Mean IPA was significantly lower with ticagrelor than clopidogrel between 48 and 168 h post‐dose (P < 0.01). Similar findings were observed with the other assays. The average time for IPA to decline from 30% to 10% was 50.8 h with ticagrelor vs. 110.4 h with clopidogrel. Conclusions: In patients with HPI, recovery of platelet function was more rapid after discontinuation of ticagrelor than clopidogrel leading to significantly greater platelet reactivity by 48 h after the last dose in the ticagrelor group.     

Reversal of the anti‐platelet effects of aspirin and clopidogrel

Summary. Background: Guidelines recommend stopping aspirin and clopidogrel 7 to 10 days before surgery to allow time for replacement of permanently inhibited platelets by newly released uninhibited platelets.Objectives: The purpose of the present study was to determine the rate of offset of the anti‐platelet effects of aspirin and clopidogrel after stopping treatment and the proportion of untreated donor platelets that are required to reverse their anti‐platelet effects.Methods: Cohort 1 consisted of 15 healthy subjects who received aspirin 81 mg day^?1 or clopidogrel 75 mg day^?1 for 7 days and underwent serial blood sampling until platelet function testing results normalized. Cohort 2 consisted of 36 healthy subjects who received aspirin 325 mg day^?1, clopidogrel 75 mg day^?1, aspirin 81 mg day^?1 plus clopidogrel 75 mg day^?1 or no treatment for 7 days and underwent a single blood sampling.Results: In cohort 1, arachidonic acid (AA)‐induced light transmission aggregation (LTA) returned to baseline levels in all subjects within 4 days of stopping aspirin, coinciding with the partial recovery of plasma thromboxane B₂ concentrations. ADP‐induced LTA did not return to baseline levels until 10 days after stopping clopidogrel. In cohort 2, AA‐induced LTA in patient treated with aspirin reached control levels after mixing with 30% untreated donor platelets whereas ADP‐induced LTA in patients treated with clopidogrel reached control levels only after the addition of 90% or more donor platelets.Conclusions: Platelet aggregation recovers within 4 days of stopping aspirin but clopidogrel must be stopped for 10 days to achieve a normal aggregatory response.     

P2Y12 protects platelets from apoptosis via PI3k‐dependent Bak/Bax inactivation

Summary. Background: Platelet ADP receptor P2Y₁₂ is well studied and recognized as a key player in platelet activation, hemostasis and thrombosis. However, the role of P2Y₁₂ in platelet apoptosis remains unknown. Objectives: To evaluate the role of the P2Y₁₂ receptor in platelet apoptosis. Methods: We used flow cytometry and Western blotting to assess apoptotic events in platelets treated with ABT‐737 or ABT‐263, and stored at 37 °C, combined with P2Y₁₂ receptor antagonists or P2Y₁₂‐deficient mice. Results: P2Y₁₂ activation attenuated apoptosis induced by ABT‐737 in human and mouse platelets in vitro, evidenced by reduced phosphatidylserine (PS) exposure, diminished depolarization of mitochondrial inner transmembrane potential (ΔΨm) and decreased caspase‐3 activation. Through increasing the phosphorylation level of Akt and Bad, and changing the interaction between different Bcl‐2 family proteins, P2Y₁₂ activation inactivated Bak/Bax. This antiapoptotic effect could be abolished by P2Y₁₂ antagonism or PI3K inhibition. We also observed the antiapoptotic effect of P2Y₁₂ activation in platelets stored at 37 °C. P2Y₁₂ activation improved the impaired activation responses of apoptotic platelets stressed by ABT‐737. In platelets from mice dosed with ABT‐263 in vivo, clopidogrel or deficiency of P2Y₁₂ receptor enhanced apoptosis along with increased Bak/Bax activation. Conclusions: This study demonstrates that P2Y₁₂ activation protects platelets from apoptosis via PI3k‐dependent Bak/Bax inactivation, which may be physiologically important to counter the proapoptotic challenge. Our findings that P2Y₁₂ blockade exaggerates platelet apoptosis induced by ABT‐263 (Navitoclax) also imply a novel drug interaction of ABT‐263 and P2Y₁₂ antagonists.     

Which platelet function test is suitable to monitor clopidogrel responsiveness? A pharmacokinetic analysis on the active metabolite of clopidogrel

Summary. Background: Multiple platelet function tests claim to be P2Y12‐pathway specific and capable of capturing the biological activity of clopidogrel. Objectives: The aim of the present study was to determine which platelet function test provides the best reflection of the in vivo plasma levels of the active metabolite of clopidogrel (AMC). Patients/methods: Clopidogrel‐naive patients scheduled for elective percutaneous coronary intervention (PCI) received a 600 mg loading dose of clopidogrel and 100 mg of aspirin. For pharmacokinetic analysis, blood was drawn at 0, 20, 40, 60, 90, 120, 180, 240 and 360 min after clopidogrel loading and peak plasma concentrations (C_max) of the AMC were quantified with liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). Platelet function testing was performed at baseline and 360 min after the clopidogrel loading. Results: The VASP‐assay, the VerifyNow P2Y12‐assay and 20 μmol L^?1 adenosine diphosphate (ADP)‐induced light transmittance aggregometry (LTA) showed strong correlations with C_max of the AMC (VASP: R² = 0.56, P < 0.001; VerifyNow platelet reactivity units (PRU): R² = 0.48, P < 0.001; VerifyNow %inhibition: R² = 0.59, P < 0.001; 20 μmol L^?1 ADP‐induced LTA: R² = 0.47, P < 0.001). Agreement with C_max of the AMC was less evident for 5 μmol L^?1 ADP‐induced LTA or whole blood aggregometry (WBA), whereas the IMPACT‐R ADP test did not show any correlation with plasmalevels of the AMC. Conclusion: The flow cytometric VASP‐assay, the VerifyNow P2Y12 assay and, although to a lesser extent, 20 μmol L^?1 ADP‐induced LTA correlate best with the maximal plasma level of the AMC, suggesting these may be the preferred platelet function tests for monitoring the responsiveness to clopidogrel.     

Aspirin withdrawal in patients treated with ticagrelor presenting with non‐ST elevation myocardial infarction

Essentials

• Strong P2Y₁₂ blockade may cause platelet inhibition that is only minimally enhanced by aspirin.
• We evaluated aspirin withdrawal on platelet reactivity in ticagrelor treated patients.
• Aspirin withdrawal resulted in increased platelet reactivity to arachidonic acid.
• Aspirin withdrawal caused little difference in adenosine diphosphate‐induced platelet aggregation.

Summary

Background

Recent studies have shown that the thromboxane A₂‐dependent pathway is dependent on the ADP–P2Y₁₂ pathway, and that strong P2Y₁₂ receptor blockade alone causes inhibition of platelet aggregation that is minimally enhanced by aspirin. Data from the PLATO trial suggested that, among ticagrelor‐treated patients, high‐dose versus low‐dose (< 100 mg day^?1) aspirin is associated with an increased risk fof ischemic events.

Objectives

To evaluate the impact of aspirin withdrawal on platelet reactivity in acute coronary syndrome (ACS) patients treated with a potent P2Y₁₂ blocker.

Patients/Methods

This was a current prospective, randomized, placebo‐controlled, double‐blind, cross‐over study. The study population comprised 22 consecutive ACS patients who underwent percutaneous coronary intervention and were treated with aspirin (100 mg day^?1) and ticagrelor. Thirty days post‐ACS, open‐label aspirin was stopped, and patients were randomized to either blinded aspirin or placebo for 2 weeks, with each patient crossing over to the other arm for an additional 2 weeks. Platelet reactivity to arachidonic acid and ADP determined with light‐transmission aggregometry (LTA) and VerifyNow was evaluated at baseline, and 2 weeks and 4 weeks later.

Results

Aspirin withdrawal resulted in an increase in arachidonic‐acid induced platelet reactivity as determined with both LTA (77.0% ± 11.3% versus 20.8% ± 4.4%) and VerifyNow (607.7 ± 10.6 aspirin reaction units [ARU] versus 408.5 ± 14.4 ARU). Platelet response to ADP, as determined with both LTA and VerifyNow, did not differ with either aspirin or placebo (32.9% ± 2.6% versus 35.8% ± 3.6%, and 33.5 ± 6.4 P2Y₁₂ reaction units (PRU) versus 29.6 ± 5.7 PRU, respectively).

Conclusions

Aspirin withdrawal early post‐ACS results in increased platelet reactivity in response to arachidonic acid, despite concomitant treatment with the potent P2Y₁₂ blocker ticagrelor.

     

Modified diadenosine tetraphosphates with dual specificity for P2Y1 and P2Y12 are potent antagonists of ADP‐induced platelet activation

Chang H, Yanachkov IB, Dix EJ, Li YF, Barnard MR, Wright GE, Michelson AD, Frelinger AL 3rd. Modified diadenosine tetraphosphates with dual specificity for P2Y₁ and P2Y₁₂ are potent antagonists of ADP‐induced platelet activation. J Thromb Haemost 2012; 10: 2573–80. Summary. Background: Diadenosine 5′,5′′′‐P¹,P⁴‐tetraphosphate (Ap₄A), a natural compound stored in platelet dense granules, inhibits ADP‐induced platelet aggregation. Ap₄A inhibits the platelet ADP receptors P2Y₁ and P2Y₁₂, is a partial agonist of P2Y₁₂, and is a full agonist of the platelet ATP‐gated ion channel P2X1. Modification of the Ap₄A tetraphosphate backbone enhances inhibition of ADP‐induced platelet aggregation. However, the effects of these Ap₄A analogs on human platelet P2Y₁, P2Y₁₂ and P2X1 are unclear. Objective: To determine the agonist and antagonist activities of diadenosine tetraphosphate analogs towards P2Y₁, P2Y₁₂, and P2X1. Methods: We synthesized the following Ap₄A analogs: P¹,P⁴‐dithiotetraphosphate; P²,P³‐chloromethylenetetraphosphate; P¹‐thio‐P²,P³‐chloromethylenetetraphosphate; and P¹,P⁴‐dithio‐P²,P³‐chloromethylenetetraphosphate. We then measured the effects of these analogs on: (i) ADP‐induced platelet aggregation; (ii) P2Y₁‐mediated changes in cytosolic Ca²⁺; (iii) P2Y₁₂‐mediated changes in vasodilator‐stimulated phosphoprotein phosphorylation; and (iv) P2X1‐mediated entry of extracellular Ca²⁺.Results: Ap₄A analogs with modifications in the phosphate backbone inhibited both P2Y₁ and P2Y₁₂, and showed no agonist activity towards these receptors. The dithio modification increased inhibition of P2Y₁, P2Y₁₂, and platelet aggregation, whereas the chloromethylene modification increased inhibition of P2Y₁₂ and platelet aggregation, but decreased P2Y₁ inhibition. Combining the dithio and chloromethylene modifications increased P2Y₁ and P2Y₁₂ inhibition. As compared with Ap₄A, each modification decreased agonist activity towards P2X1, and the dual modification completely eliminated P2X1 agonist activity. Conclusions: As compared with Ap₄A, tetraphosphate backbone analogs of Ap₄A have diminished activity towards P2X1 but inhibit both P2Y₁ and P2Y₁₂ and, with greater potency, inhibit ADP‐induced platelet aggregation. Thus, diadenosine tetraphosphate analogs with dual receptor selectivity may have potential as antiplatelet drugs.     

Smoking behaviour modulates pharmacokinetics of orally administered clopidogrel

Background and objectives: Clopidogrel is an important antiplatelet drug that is effective in preventing thrombotic events, especially for patients undergoing percutaneous coronary intervention. The therapeutic usefulness of clopidogrel has been limited by documented inter‐individual heterogeneity in platelet inhibition, which may be attributable to known clopidogrel pharmacokinetic variability. The objective of this study was to assess the influence of smoking cigarettes and abnormal body weight on the pharmacokinetics of clopidogrel. Methods: Seventy‐six healthy adult male volunteers were selected randomly. Each subject received a single 75 mg oral dose of clopidogrel after overnight fast. Clopidogrel carboxylate plasma levels were measured and non‐compartmental analysis was used to determine peak plasma concentration (C_max), time to peak plasma concentration (T_max), elimination half‐life (t_1/2e), and area under the curve (AUC_0→∞). Results: One‐third of volunteers were smokers (n = 27) and one‐half had abnormal body weight (n = 39). Smokers had lower AUC_0→∞ (smokers: 6·24 ± 2·32 μg/h/mL vs. non‐smokers: 8·93 ± 3·80 μg/h/mL, P < 0·001) and shorter half‐life (smokers: 5·46 ± 2·99 vs. non‐smokers: 8·43 ± 4·26, P = 0·001). Smoking behaviour had no influence on C_max (P = 0·3) and T_max (P = 0·7). There was no statistically significant difference in C_max, AUC_0→∞, T_max and t_1/2e between volunteers with abnormal body weight and normal body weight. However the difference in body weight of the two groups was relatively narrow (mean ± SE; 26·93 ± 0·16 vs. 23·11 ± 0·27). In general, the pharmacokinetic parameters were characterized by considerable inter‐individual differences (C_max = 3·09 ± 0·99 μg/mL, CV = 32%), (T_max =0·76 ± 0·24 h, CV = 31·6%), (AUC_0→∞ = 7·98 ± 3·58 μg/h/mL, CV = 44·8%), and (t_1/2e = 7·38 ± 4·10 h, CV = 55·6%). Conclusion: Smoking is a significant factor affecting the pharmacokinetics of clopidogrel, following administration of a single 75 mg dose in healthy young volunteers. The study supports smoking‐cessation recommendations. Further studies are required to evaluate the influence of smoking and body weight on the pharmacokinetics of the active metabolite of clopidogrel and on the clinical effects of any differences observed.     

Enhanced antiplatelet effect of clopidogrel in patients whose platelets are least inhibited by aspirin: a randomized crossover trial

Summary. Objective: We aimed to determine whether adding clopidogrel to aspirin in patients at high risk of future cardiovascular events would suppress laboratory measures of the antiplatelet effects of aspirin; and have greater platelet inhibitory effects in patients with the least inhibition of platelets by aspirin. Methods: We performed a randomized, double‐blind, placebo‐controlled, crossover trial, comparing clopidogrel 75 mg day^?1 versus placebo, in 36 aspirin‐treated patients with symptomatic objectively confirmed peripheral arterial disease. Results: The addition of clopidogrel to aspirin did not suppress platelet aggregation induced by arachidonic acid, urinary 11 dehydro thromboxane B₂ concentrations, or soluble markers of platelet activation markers (P‐selectin, CD40‐ligand) and inflammation (high sensitivity serum C‐reactive protein, interleukin‐6). Clopidogrel significantly inhibited platelet aggregation induced by ADP (reduction 26.2%; 95% CI: 21.3–31.1%, P < 0.0001) and collagen (reduction 6.2%; 95% CI: 3.2–9.3%, P = 0.0003). The greatest inhibition of collagen‐induced platelet aggregation by clopidogrel was seen in patients with the least inhibition of arachidonic acid induced aggregation by aspirin [lower tertile of arachidonic acid‐induced platelet aggregation: 2.8% (95% CI: ?0.8 to 6.3%) reduction in mean collagen‐induced aggregation by clopidogrel; middle tertile: 4.0% (95% CI: 0.4–7.6%); upper tertile 12.6% (95% CI: 4.5–20.8%); P‐value for interaction 0.01]. Conclusions: The greatest platelet inhibitory effect of clopidogrel occurs in patients with the least inhibition of arachidonic acid‐induced platelet aggregation by aspirin. This raises the possibility that the clinical benefits of adding clopidogrel to aspirin may be greatest in patients whose platelets are least inhibited by aspirin. Confirmation in clinical outcome studies may allow these patients to be targeted with antiplatelet drugs that inhibit the ADP receptor, thereby overcoming the problem of laboratory aspirin resistance.     

Arterial antithrombotic and bleeding time effects of apixaban,a direct factor Xa inhibitor,in combination with antiplatelet therapy in rabbits

Summary. Background: Optimal treatment of arterial thrombosis may include a combination of antiplatelet and anticoagulant drugs. We evaluated apixaban, a direct and highly selective factor Xa inhibitor, in combination with clinically relevant doses of aspirin and/or clopidogrel for prevention of arterial thrombosis in rabbits. Methods: Studies were conducted in rabbit models of electrically induced carotid artery thrombosis and cuticle bleeding time (BT). Apixaban 0.04 and 0.3 mg kg^?1 h^?1 or aspirin 1 mg kg^?1 h^?1 was infused intravenous (i.v.) continuously from 1 h before artery injury or cuticle bleed until the end of the experiment. Clopidogrel at 3 mg kg^?1 was dosed orally once daily for three days, with the last dose given 2 h before injury. Results: Control thrombus weight and BT averaged 8.6 ± 0.9 mg and 181 ± 12 s, respectively (n = 6 per group). Effective doses of apixaban that reduced thrombus weight by 20 and 50% (ED₂₀ and ED₅₀) were 0.04 and 0.3 mg kg^?1 h^?1 i.v., respectively. Addition of aspirin to apixaban ED₂₀ and ED₅₀ significantly reduced the thrombus weight from 7.4 ± 0.5 to 5.3 ± 0.3 and 3.6 ± 0.3 mg, respectively, with no significant increases in BT (190 ± 7 s vs.181 ± 9 and 225 ± 11 s, respectively). Addition of aspirin and apixaban (ED₂₀ dose) to clopidogrel produced a further significant reduction in thrombus weight from 5.3 ± 0.3 to 0.7 ± 0.1 mg. This combination of clopidogrel and aspirin with apixaban (ED₂₀ dose) produced a significant but moderate BT increase of 2.1 times control. Conclusions: The combination of apixaban and aspirin or apixaban, aspirin and clopidogrel can reduce formation of occlusive arterial thrombosis without excessive increases in BT in rabbits.     

Decreased platelet inhibition by P2Y12 receptor blockers in anaemia

Background

Anaemic patients undergoing angioplasty and stenting are at an increased risk of ischaemic events, which may be caused by an inadequate response to antiplatelet therapy with adenosine diphosphate (ADP) P2Y₁₂ inhibitors. In the current study, we investigated the associations between anaemia and on‐treatment platelet reactivity in clopidogrel‐treated (group 1, n = 306) and prasugrel‐/ticagrelor‐treated (group 2, n = 109) patients undergoing elective and acute angioplasty with stent implantation, respectively.

Materials and methods

Monocyte‐platelet aggregate (MPA) formation was determined by flow cytometry in both groups. On‐treatment residual platelet reactivity in response to ADP was assessed by light transmission aggregometry (LTA) in both groups, and by the VerifyNow P2Y₁₂ assay and the Impact‐R in group 1. P‐selectin expression was measured by flow cytometry in group 2.

Results

In both groups, anaemia was associated with significantly higher MPA formation in response to ADP (both P ≤ .02). Moreover, by LTA maximal aggregation in response to ADP was significantly higher in patients with anaemia in both groups (both P < .05), and anaemic patients in group 1 had a significantly higher on‐treatment platelet reactivity by the VerifyNow P2Y₁₂ assay and the Impact‐R than those without anaemia (both P < .001). In group 2, significantly higher platelet surface expression of P‐selectin was seen in anaemia after stimulation with ADP (P = .02).

Conclusion

Anaemia is associated with decreased platelet inhibition by ADP P2Y₁₂ receptor antagonists after elective and acute percutaneous interventions with stent implantation. However, due to inconsistencies between different platelet function tests additional data are needed to clarify the role of anaemia for platelet inhibition.     

Antiplatelet effects of prasugrel vs. double clopidogrel in patients on hemodialysis and with high on‐treatment platelet reactivity

Summary. Background: High on‐treatment platelet reactivity (HTPR) is frequent in patients on hemodialysis (HD) receiving clopidrogel. Objectives: The primary aim of this study was to determine the antiplatelet effects of prasugrel vs. high‐dose clopidogrel in patients on HD with HTPR. Patients/Methods: We performed a prospective, single‐center, single‐blind, investigator‐initiated, randomized, crossover study to compare platelet inhibition by prasugrel 10 mg day^?1 with that by high‐dose 150 mg day^?1 clopidogrel in 21 patients on chronic HD with HTPR. Platelet function was assessed with the VerifyNow assay, and genotyping was performed for CYP2C19*2 carriage. Results: The primary endpoint of platelet reactivity (PR, measured in P2Y12 reaction units [PRU]) was lower in patients receiving prasugrel (least squares [LS] estimate 156.6, 95% confidence interval [CI] 132.2–181.1) than in those receiving high‐dose clopidogrel (LS 279.9, 95% CI 255.4–304.3), P < 0.001). The LS mean differences between the two treatments were ? 113.4 PRU (95% CI ? 152.9 to ? 73.8, P < 0.001) and ? 163.8 PRU (95% CI ? 218.1 to ? 109.2, P < 0.001) in non‐carriers and carriers of at least one CYP2C19*2 allele, respectively. HTPR rates were lower for prasugrel than clopidogrel, in all patients (19% vs. 85.7%, P < 0.001) and in non‐carriers (25.7% vs. 80%, P = 0.003). All carriers continued to show HTPR while receiving high‐dose clopidogrel, but none showed it while receiving prasugrel. Conclusions: In HD patients exhibiting HTPR following standard clopidogrel treatment, prasugrel 10 mg day^–1 is significantly more efficient than doubling the clopidogrel dosage in achieving adequate platelet inhibition. Neither effect seems to be influenced by carriage of the loss‐of‐function CYP2C19*2 allele.     

Determinants of high on-treatment platelet reactivity and agreement between VerifyNow and Multiplate assays

Dual antiplatelet therapy with clopidogrel is a regimen used before and after drug-eluting stent (DES) implantation. Point-of-care platelet reactivity assays are easy-to-use methods to determine adequate response to the drug. The aim of this study was a comparison of the two platelet reactivity assays: Multiplate^® and VerifyNow^® and an identification of factors potentially influencing the results of these tests, including common genetic polymorphisms. The study included 39 patients receiving 75?mg clopidogrel daily before angioplasty with DES implantation. Platelet reactivity was measured with Multiplate and P2Y₁₂ VerifyNow assays. Genetic polymorphisms of CYP2C19*2, ABCB1 3435C?>?T, and CYP3A4*1G were determined with PCR-RFLP method and CYP2C19*17 was determined by means of an allele-specific PCR. Agreement between Multiplate and VerifyNow assays was poor (Cohen’s κ?=?0.056, p?=?.273). Hematocrit significantly negatively correlated with VerifyNow assayed platelet reactivity (r?=??.487, p?=?.002). Female sex was significantly associated with higher VerifyNow assay results after adjustment to hematocrit (253.2?±?47.6 PRU vs. 195.9?±?56.9 PRU, p?=?.013) and the prevalence of high-on-treatment platelet reactivity (OR: 8.50; 95% CI 1.13–77.60, p?=?.024). Reactivity measured with Multiplate was lower in women (82.3 vs. 175.6?AU·min, p?=?.037) and in patients who received calcium channel blockers (74.7 vs. 191.7?AU·min, p?=?.002). None of the studied polymorphisms significantly influenced platelet aggregation measurements. In conclusion, different aspects modify between-patient variability of the Multiplate and VerifyNow assays and agreement between those two assays was poor.     

Contribution of the P2Y12 receptor‐mediated pathway to platelet hyperreactivity in hypercholesterolemia

Summary. Background: In hypercholesterolemia, platelets demonstrate increased reactivity and promote the development of cardiovascular disease. Objective: This study was carried out to investigate the contribution of the ADP receptor P2Y12‐mediated pathway to platelet hyperreactivity due to hypercholesterolemia. Methods: Low‐density lipoprotein receptor‐deficient mice and C57Bl/6 wild‐type mice were fed on normal chow and high‐fat (Western or Paigen) diets for 8 weeks to generate differently elevated cholesterol levels. P2Y12 receptor‐induced functional responses via G_i signaling were studied ex vivo when washed murine platelets were activated by 2MeSADP and PAR4 agonist AYPGKF in the presence and absence of indomethacin. Platelet aggregation and secretion, α_IIbβ₃ receptor activation and the phosphorylation of extracellular signal‐regulated protein kinase (ERK) and Akt were analyzed. Results: Plasma cholesterol levels ranged from 69 ± 10 to 1011 ± 185 mg dL^?1 depending on diet in mice with different genotypes. Agonist‐dependent aggregation, dense and α‐granule secretion and JON/A binding were gradually and significantly (P < 0.05) augmented at low agonist concentration in correlation with the increasing plasma cholesterol levels, even if elevated thromboxane generation was blocked. These functional responses were induced via increased levels of G_i‐mediated ERK and Akt phosphorylation in hypercholesterolemic mice vs. normocholesterolemic animals. In addition, blocking of the P2Y12 receptor by AR‐C69931MX (Cangrelor) resulted in strongly reduced platelet aggregation in mice with elevated cholesterol levels compared with normocholesterolemic controls. Conclusions: These data revealed that the P2Y12 receptor pathway was substantially involved in platelet hyperreactivity associated with mild and severe hypercholesterolemia.     

A Gi‐independent mechanism mediating Akt phosphorylation in platelets

Summary. Background: The serine‐threonine kinase Akt plays an important role in regulating platelet activation. Stimulation of platelets with various agonists results in Akt activation as indicated by Akt phosphorylation. However, the mechanisms of Akt phosphorylation in platelets are not completely understood. Objectives and Methods: We used P2Y₁₂ knockout mice to address the role of P2Y₁₂ in Akt phosphorylation in response to thrombin receptors in platelets. Results: Thrombin or the PAR4 thrombin receptor peptide AYPGKF at high concentrations stimulated substantial phosphorylation of Akt residues Thr³⁰⁸ and Ser⁴⁷³ in P2Y₁₂‐deficient platelets. AYPGKF‐induced Akt phosphorylation is enhanced by expression of recombinant human PAR4 cDNA in Chinese hamster ovary (CHO) cells. P2Y₁₂‐independent Akt phosphorylation was not inhibited by integrin inhibitor peptide RGDS or integrin β₃ deficiency. Akt phosphorylation induced by thrombin or AYPGKF in P2Y₁₂‐deficient platelets was inhibited by the calcium chelator dimethyl‐BAPTA, the Src family kinase inhibitor PP2, and PI3K inhibitors, respectively. Conclusions: Our results reveal a novel P2Y₁₂‐independent signaling pathway mediating Akt phosphorylation in response to thrombin receptors.     

Protective effects of triflusal on secondary thrombus growth and vascular cyclooxygenase-2

Summary. Background: Carotid residual mural thrombus predisposes to recurrent thrombosis and/or distal embolization (i.e. cerebrovascular ischemia). Objectives: Our aims were (i) to analyze and compare the efficacy of aspirin, triflusal, and its main metabolite 2‐hydroxy‐4‐trifluorometylbenzoic acid (HTB) on secondary thrombus growth; and (ii) evaluate to what extent the three Cox‐1 inhibitors influenced vascular Cox‐1/Cox‐2 expression and endothelial prostacyclin synthesis. Methods: In a rabbit model of ex vivo thrombosis, a fresh mural thrombus was formed on damaged vessels at flow conditions typical of mild and severe carotid stenoses. The effects of Cox‐1 inhibitors administered both intravenously (i.v.) (aspirin 5 mg kg^?1, triflusal 10 mg kg^?1, and HTB 10 mg kg^?1) and orally (p.o.) (8 days; aspirin 30 mg kg^?1 day^?1, and triflusal 40 mg kg^?1 day^?1) on secondary thrombus growth were assessed by In‐¹¹¹deposited platelets and compared with a placebo control. Arterial Cox‐1/Cox‐2 expression after 8‐day treatment was evaluated at mRNA and protein levels. Additionally, a drug‐related dose‐dependent in vitro assay was performed for endothelial PGI₂ release measurement (Cox‐2 activity). Results: All Cox inhibitors similarly and significantly (P < 0.05) reduced secondary thrombus formation after i.v. and p.o. administration versus placebo control. Treatments exerted no effect on vascular Cox‐1 mRNA whereas Cox‐2 mRNA was moderately reduced by aspirin and triflusal (placebo 100% ± 9%, aspirin 70% ± 2% and triflusal 70% ± 2%; P < 0.05). Cox‐2 protein levels were slightly higher in the triflusal versus aspirin group (placebo 100% ± 6%, aspirin 35% ± 10% and triflusal 61% ± 9%; P < 0.005 versus placebo). Interestingly, in vitro, HTB solely maintained endothelial PGI₂ synthesis levels similar to the control. Conclusions: At a similar level of efficacy in inhibiting secondary thrombosis, triflusal seems to better preserve Cox‐2 expression than aspirin and its metabolite HTB was able to protect endothelial prostacyclin production.     

Bleeding risk with AZD6140, a reversible P2Y12 receptor antagonist,vs. clopidogrel in patients undergoing coronary artery bypass grafting in the DISPERSE2 trial

AZD6140, the first reversible oral P2Y₁₂ receptor antagonist, exhibits greater and more consistent inhibition of platelet aggregation than the irreversible thienopyridine clopidogrel. As a result of its reversible effect, AZD6140 may pose less risk for bleeding when antiplatelet treatment cannot be stopped at least 5 days before coronary artery bypass graft (CABG) surgery or other invasive procedures. The Dose conflrmation Study assessing anti‐Platelet Effects of AZD6140 vs. clopidogRel in NSTEMI (DISPERSE2) trial showed overall comparable bleeding rates with antiplatelet treatment with AZD6140 90 mg twice daily or 180 mg twice daily vs. clopidogrel 75 mg once daily in 984 patients with non‐ST‐elevation acute coronary syndromes. A post hoc exploratory analysis of bleeding outcomes in the subset of 84 patients undergoing CABG in DISPERSE2 suggests reduced risk for total bleeding (41% and 58% vs. 62%), all major bleeding (38% and 50% vs. 62%), and life‐threatening bleeding (22% and 38% vs. 54%) with AZD6140 90 mg (n = 32) and 180 mg (n = 26) vs. clopidogrel (n = 26) respectively. Trends suggested that major bleeding rates were reduced with AZD6140 (combined groups) vs. clopidogrel when treatment was stopped ≤ 5 days prior to surgery (39% vs. 63%, p = 0.15) but not when treatment was stopped > 5 days before surgery (50% vs. 60%). This observation is consistent with the reversible binding of AZD6140 to the P2Y₁₂ receptor. Further prospective studies are planned to assess the relationship between this potential clinical benefit of AZD6140 and the reversibility of its antiplatelet effects.