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DOI: 10.1055/a-2075-7979
Identification of High Platelet Reactivity Despite ADP P2Y12 Inhibitor Treatment: Two Populations in the Vasodilator-Stimulated Phosphoprotein Assay and Variable PFA-P2Y Shapes of Curve
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Abstract
Introduction Response to ADP P2Y12 receptor inhibition by clopidogrel can be evaluated by various techniques. Here, we compared a functional rapid point-of-care technique (PFA-P2Y) with the degree of biochemical inhibition assessed by the VASP/P2Y12 assay.
Methods Platelet response to clopidogrel was investigated in 173 patients undergoing elective intracerebral stenting (derivation cohort n = 117; validation cohort n = 56). High platelet reactivity (HPR) was defined as PFA-P2Y occlusion time <106 seconds or VASP/P2Y12 platelet reactivity index (PRI) >50%.
Results In the derivation cohort, receiver operator characteristics analysis for the ability of PFA-P2Y to detect biochemical HPR showed high specificity (98.4%) but poor sensitivity (20.0%) and a very low area under the curve (0.59). The VASP/P2Y12 assay revealed two coexisting platelet populations with different levels of vasodilator-stimulated phosphoprotein (VASP) phosphorylation: a fraction of highly phosphorylated, inhibited platelets and another of poorly phosphorylated, reactive platelets. Analysis of the PFA-P2Y curve shape revealed different types, categorized by time of occlusion (<106 seconds, 106 to 300 seconds, >300 seconds), and pattern (regular, irregular, and atypical). Noteworthy, curves with late occlusion and permeable curves with an irregular or atypical pattern correlated with VASP-PRI >50% and smaller sizes of the inhibited platelet subpopulation. Considering the PFA-P2Y shape of the curve for the detection of HPR improved sensitivity (72.7%) and preserved specificity (91.9%), with a rather high AUC (0.823). The validation cohort confirmed the VASP/P2Y12 assay data and the usefulness of considering the PFA-P2Y curve shape.
Conclusion In patients treated with acetylsalicylic acid and clopidogrel for 7-10 days, the VASP/P2Y12 assay reveals two coexisting subpopulations of differentially inhibited platelets, whose relative sizes predict global PRI and distinct PFA-P2Y curve patterns, indicating incomplete clopidogrel efficacy. The detailed analysis of both VASP/P2Y12 and PFA-P2Y is necessary for optimal detection of HPR.
Author Contributions
Cy.M. performed research, analyzed data, and wrote the manuscript. E.S. analyzed data and edited the manuscript. E.M.G. performed research.
J.B.R. analyzed data. F.J.G. performed research.
F.G. edited the manuscript. Ca.M. analyzed data and wrote the manuscript. L.A. conceived research, analyzed data, and wrote the manuscript. All authors read and approved the submitted version of the manuscript.
* shared first authorship
Publication History
Received: 26 October 2022
Accepted: 03 April 2023
Accepted Manuscript online:
18 April 2023
Article published online:
07 June 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG
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References
- 1 Cuisset T, Frere C, Quilici J. et al. High post-treatment platelet reactivity identified low-responders to dual antiplatelet therapy at increased risk of recurrent cardiovascular events after stenting for acute coronary syndrome. J Thromb Haemost 2006; 4 (03) 542-549
- 2 Tantry US, Bonello L, Aradi D. et al; Working Group on On-Treatment Platelet Reactivity. Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol 2013; 62 (24) 2261-2273
- 3 Goedel A, Fiedler KA, Mehilli J. et al. Enhanced platelet inhibition by clopidogrel and risk of bleeding in patients requiring oral anticoagulation after drug-eluting stent implantation. EuroIntervention 2019; 15 (08) 700-706
- 4 Helten C, Naguib D, Dannenberg L. et al. Platelet function testing: dead or alive. J Thromb Haemost 2018; 16 (05) 984-986
- 5 Cuisset T, Cayla G, Silvain J. Clopidogrel resistance: what's new?. Arch Cardiovasc Dis 2010; 103 (6-7): 349-353
- 6 Dyszkiewicz-Korpanty A, Olteanu H, Frenkel EP, Sarode R. Clopidogrel anti-platelet effect: an evaluation by optical aggregometry, impedance aggregometry, and the platelet function analyzer (PFA-100). Platelets 2007; 18 (07) 491-496
- 7 Pampuch A, Cerletti C, de Gaetano G. Comparison of VASP-phosphorylation assay to light-transmission aggregometry in assessing inhibition of the platelet ADP P2Y12 receptor. Thromb Haemost 2006; 96 (06) 767-773
- 8 Gurbel PA, Bliden KP, Hiatt BL, O'Connor CM. Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation 2003; 107 (23) 2908-2913
- 9 Kim Y, Weissler EH, Pack N, Latz CA. A systematic review of clopidogrel resistance in vascular surgery: current perspectives and future directions. Ann Vasc Surg 2023; 91: 257-265
- 10 Cavallari LH, Obeng AO. Genetic determinants of P2Y12 inhibitors and clinical implications. Interv Cardiol Clin 2017; 6 (01) 141-149
- 11 Bates ER, Lau WC, Angiolillo DJ. Clopidogrel-drug interactions. J Am Coll Cardiol 2011; 57 (11) 1251-1263
- 12 Wiviott SD, Antman EM. Clopidogrel resistance: a new chapter in a fast-moving story. Circulation 2004; 109 (25) 3064-3067
- 13 Galli M, Benenati S, Franchi F. et al. Comparative effects of guided vs. potent P2Y12 inhibitor therapy in acute coronary syndrome: a network meta-analysis of 61 898 patients from 15 randomized trials. Eur Heart J 2022; 43 (10) 959-967
- 14 Siller-Matula JM, Trenk D, Schrör K. et al; EPA (European Platelet Academy). Response variability to P2Y12 receptor inhibitors: expectations and reality. JACC Cardiovasc Interv 2013; 6 (11) 1111-1128
- 15 Michelson AD, Bhatt DL. How I use laboratory monitoring of antiplatelet therapy. Blood 2017; 130 (06) 713-721
- 16 Rokosh RS, Rockman C, Garg K. et al. Multi-institutional patterns of clopidogrel response among patients undergoing transcarotid artery revascularization. Vascular 2022 (e-pub ahead of print). doi: 17085381221142219
- 17 Frere C, Cuisset T, Quilici J. et al. ADP-induced platelet aggregation and platelet reactivity index VASP are good predictive markers for clinical outcomes in non-ST elevation acute coronary syndrome. Thromb Haemost 2007; 98 (04) 838-843
- 18 Hu C, Zhang X, Liu Y. et al. Vasodilator-stimulated phosphoprotein-guided Clopidogrel maintenance therapy reduces cardiovascular events in atrial fibrillation patients requiring anticoagulation therapy and scheduled for percutaneous coronary intervention: a prospective cohort study. BMC Cardiovasc Disord 2018; 18 (01) 120
- 19 Tsantes A, Ikonomidis I, Papadakis I. et al. Evaluation of the role of the new INNOVANCE PFA P2Y test cartridge in detection of clopidogrel resistance. Platelets 2012; 23 (06) 481-489
- 20 Mallouk N, Varvat J, Berger A. et al. Assessment of a flow cytometry technique for studying signaling pathways in platelets: monitoring of VASP phosphorylation in clinical samples. Pract Lab Med 2018; 11: 10-18
- 21 Mingant F, Didier R, Gilard M. et al. Comparison of four methods to assess high-on platelet reactivity under P2Y12 receptor inhibitor. Platelets 2018; 29 (03) 257-264
- 22 Jurk K, Shiravand Y. Platelet phenotyping and function testing in thrombocytopenia. J Clin Med 2021; 10 (05) 1114
- 23 Pedrazzini G, Biasco L, Sulzer I. et al. Acquired intracoronary ADAMTS13 deficiency and VWF retention at sites of critical coronary stenosis in patients with STEMI. Blood 2016; 127 (23) 2934-2936
- 24 Ibrahim H, Nadipalli S, DeLao T, Guthikonda S, Kleiman NS. Immature platelet fraction (IPF) determined with an automated method predicts clopidogrel hyporesponsiveness. J Thromb Thrombolysis 2012; 33 (02) 137-142
- 25 Pascale S, Petrucci G, Dragani A. et al. Aspirin-insensitive thromboxane biosynthesis in essential thrombocythemia is explained by accelerated renewal of the drug target. Blood 2012; 119 (15) 3595-3603
- 26 Del Bianco-Rondeau M, Robert-Halabi M, Bloom S. et al. Aspirin for primary cardiovascular prevention in patients with diabetes: uncertainties and opportunities. Thromb Haemost 2022; 122 (09) 1443-1453
- 27 Needs CJ, Brooks PM. Clinical pharmacokinetics of the salicylates. Clin Pharmacokinet 1985; 10 (02) 164-177
- 28 Clarke RJ, Mayo G, Price P, FitzGerald GA. Suppression of thromboxane A2 but not of systemic prostacyclin by controlled-release aspirin. N Engl J Med 1991; 325 (16) 1137-1141
- 29 Kuijpers MJ, Megens RT, Nikookhesal E. et al. Role of newly formed platelets in thrombus formation in rat after clopidogrel treatment: comparison to the reversible binding P2Y12 antagonist ticagrelor. Thromb Haemost 2011; 106 (06) 1179-1188
- 30 Shahidi M. Thrombosis and von Willebrand Factor. Adv Exp Med Biol 2017; 906: 285-306
- 31 Stalder G, Chatte A, De Rossi N, Yerly P, Alberio L, Eeckhout E. Caplacizumab for treating subacute intra-stent thrombus occurring despite efficacious double anti-platelet treatment and anticoagulation: a case report. Eur Heart J Case Rep 2023; 7 (02) ytac497
- 32 Cesar JM, de Miguel D, García Avello A, Burgaleta C. Platelet dysfunction in primary thrombocythemia using the platelet function analyzer, PFA-100. Am J Clin Pathol 2005; 123 (05) 772-777
- 33 Tsantes AE, Mantzios G, Giannopoulou V. et al. Monitoring aspirin treatment in patients with thrombocytosis: comparison of the platelet function analyzer (PFA)-100 with optical aggregometry. Thromb Res 2008; 123 (01) 100-107
- 34 Angiolillo DJ, Jakubowski JA, Ferreiro JL. et al. Impaired responsiveness to the platelet P2Y12 receptor antagonist clopidogrel in patients with type 2 diabetes and coronary artery disease. J Am Coll Cardiol 2014; 64 (10) 1005-1014