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Ciccarone Articles

Ciccarone Center Research


Antiplatelet Therapy

Landmark Articles

A clinician’s guide to the updated ABCs of cardiovascular disease prevention.
By: Kohli P, Whelton SP, Hsu S, Yancy CW, Stone NJ, Chrispin J, Gilotra NA, Houston B, Ashen MD, Martin SS, Joshi PH, McEvoy JW, Gluckman TJ, Michos ED, Blaha MJ, Blumenthal RS.

To facilitate the guideline-based implementation of treatment recommendations in the ambulatory setting and to encourage participation in the multiple preventive health efforts that exist, we have organized several recent guideline updates into a simple ABCDEF approach. We would remind clinicians that evidence-based medicine is meant to inform recommendations but that synthesis of patient-specific data and use of appropriate clinical judgment in each individual situation is ultimately preferred.

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Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis.
By: Miedema MD, Duprez DA, Misialek JR, Blaha MJ, Nasir K, Silverman MG, Blankstein R, Budoff MJ, Greenland P, Folsom AR.
For the primary prevention of coronary heart disease (CHD), MESA participants with coronary artery calcium (CAC) ?100 were shown to have favorable risk/benefit estimations for aspirin use, while participants with zero CAC were estimated to receive net harm from aspirin.
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Fatty acids and TxA2 generation, in the absence of platelet-COX-1 activity.
By: DeFilippis AP, Rai SN, Cambon A, Miles R, Saenger AK, Blumenthal RS, Jaffe AS, Moser AB, Jones RO, Bolli R, Schulman SP.
This study shows that baseline omega-3 fatty acid levels do not influence TxA(2) generation in patients with or at high risk for CVD receiving adequate aspirin therapy.
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Polypill therapy, subclinical atherosclerosis, and cardiovascular events — implications for the use of preventive pharmacotherapy: MESA (Multi-Ethnic Study of Atherosclerosis).
By: Bittencourt MS, Blaha MJ, Blankstein R, Budoff M, Vargas JD, Blumenthal RS, Agatston AS, Nasir K.
The authors conclude that avoidance of polypill therapy in individuals with subclinical atherosclerosis could allow for a more selective use of the treatment and, as a result, avoidance of treatment in those who are unlikely to benefit.
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Platelet COX-1-independent TxA2 generation in patients with acute coronary syndromes.
By: DeFilippis AP, Oloyede OS, Andrikopoulou E, Saenger AK, Palachuvattil JM, Fasoro YA, Guallar E, Blumenthal RS, Kickler TK, Jaffe AS, Gerstenblith G, Schulman SP, Rade JJ.

Aspirin's therapeutic action is via inhibition of platelet cyclooxygenase 1 (COX-1) thromboxane A2 (TxA2) production. The aim of this study was to evaluate TxA2 production, in the absence of platelet COX-1 activity, in coronary atherosclerotic heart disease patients with and without atherothrombotic myocardial infarction (MI). Differences in TxA2 production, in the absence of platelet COX-1 activity, between those with vs. without atherothrombotic MI were not observed when TxA2 generation was assessed on 11-dehydro-TxB2 production alone (polyclonal ELISA or LC-MS/MS), but differences were observed when TxA2 generation was assessed using 11-dehydro-TxB2 plus 11-dehydro-2,3-dinor-TxB2 (monoclonal ELISA). These findings highlight important differences between different commercially available assays for TxA2 generation and suggest that 11-dehydro-2,3-dinor-TxB2 may be critical to the biology of atherothrombosis. 

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Genetic variation in PEAR1 is associated with platelet aggregation and cardiovascular outcomes.
By: Lewis JP, Ryan K, O’Connell JR, Horenstein RB, Damcott CM, Gibson Q, Pollin TI, Mitchell BD, Beitelshees AL, Pakzy R, Tanner K, Parsa A, Tantry US, Bliden KP, Post WS, Faraday N, Herzog W, Gong Y, Pepine CJ, Johnson JA, Gurbel PA, Shuldiner AR.
Common genetic variation in platelet endothelial aggregation receptor-1 may be a determinant of platelet response and cardiovascular events in patients on aspirin alone or in combination with clopidogrel.
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Potential implications of coronary artery calcium testing for guiding aspirin use among asymptomatic individuals with diabetes.
By: Silverman MG, Blaha MJ, Budoff MJ, Rivera JJ, Raggi P, Shaw LJ, Berman D, Callister T, Rumberger JA, Rana JS, Blumenthal RS, Nasir K.
We conclude that CAC can help risk stratify individuals with diabetes and may aid in selection of patients who may benefit from therapies such as low-dose aspirin for primary prevention of CVD.
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Impact of coronary computed tomographic angiography results on patient and physician behavior in a low-risk population.
By: McEvoy JW, Blaha MJ, Nasir K, Yoon YE, Choi EK, Cho IS, Chun EJ, Choi SI, Rivera JJ, Blumenthal RS, Chang HJ.
We studied asymptomatic patients from a large health-screening program. Our study population comprised 1,000 patients who underwent coronary CT angiography (CCTA) as part of a prior study and a matched control group of 1,000 patients who did not. We assessed medication use, secondary test referrals, revascularizations, and cardiovascular events at 90 days and 18 months. An abnormal screening CCTA result was predictive of increased aspirin and statin use at 90 days and 18 months, although medication use lessened over time. Screening CCTA was associated with increased invasive testing, without any difference in events at 18 months. Screening CCTA in asymptomatic adults should NOT be considered a justifiable test at this time.
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Preventive cardiology: past, present, and future.
By: Blaha MJ, Gluckman TJ, Blumenthal RS.
The majority of improvement in rates of mortality from CVD since 1960 has been the result of prevention strategies and not treatment of acute CVD. Prevention occurs at three levels: primordial, primary, and secondary. National guidelines direct population-based and individual-based preventive care. This chapter offers an easy to remember memory tool that facilitates comprehensive preventive care: The Ciccarone Center ABCDE approach.
Randomized clinical trial of aspirin and simvastatin for pulmonary arterial hypertension: ASA-STAT.
By: Kawut SM, Bagiella E, Lederer DJ, Shimbo D, Horn EM, Roberts KE, Hill NS, Barr RG, Rosenzweig EB, Post W, Tracy RP, Palevsky HI, Hassoun PM, Girgis RE; ASA-STAT Study Group.
Pulmonary arterial hypertension (PAH) is a progressive disease that causes exercise limitation, heart failure, and death. We performed a randomized, double-blind, placebo-controlled 2×2 factorial clinical trial to determine the safety and efficacy of aspirin and simvastatin in patients with PAH. Neither aspirin nor simvastatin had a significant effect on the 6-minute walk distance, although patients randomized to simvastatin tended to have a lower 6-minute walk distance at 6 months. These results do not support the routine treatment of patients with PAH with these medications.
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