Clopidogrel Resistance and Ticagrelor Replacement in Dual Antiplatelet Therapy for Carotid Artery Stenting

Mazzaccaro D, Giannetta M, Ranucci M, Righini P, Di Dedda U, Baryshnikova E, Milani V, Nano G. Clopidogrel Resistance and Ticagrelor Replacement in Dual Antiplatelet Therapy for Carotid Artery Stenting. Ann Vasc Surg. 2023 Mar;90:128-136. doi: 10.1016/j.avsg.2022.09.063. Epub 2022 Oct 19. PMID: 36270550. Backgrounds: Resistance to the pharmacological effect of clopidogrel in patients undergoing dual antiplatelet therapy for carotid stenting may increase the risk of periprocedural neurological events. The purpose of the study was to describe the phenomenon of clopidogrel resistance in a series of patients undergoing carotid stenting. Methods: Data of patients who consecutively underwent carotid stenting from November 2016 to December 2020 for a significant stenosis and who underwent a dual antiplatelet therapy using acetyl-salicylic acid and clopidogrel were prospectively collected. Patients who were already taking a different thienopyridine were excluded. The effectiveness of antiplatelet drugs was assessed by the impedance aggregometry test. Primary endpoint was to evaluate the incidence of clopidogrel resistance and the effectiveness of ticagrelor as alternative therapy. P values < 0.05 were considered statistically significant. Results: Two-hundred patients (80 females, 40%) underwent stenting for carotid stenosis (94% asymptomatic). The phenomenon of clopidogrel resistance was observed in 38 patients (19%), in whom clopidogrel was replaced by ticagrelor (90 mg/bis in die) with 100% effectiveness at aggregometry test. Platelet counts was associated to clopidogrel resistance (P = 0.001). There was no stent thrombosis at 30 days, neither major hemorrhagic events; a total of 12/200 major adverse cardiovascular events occurred (6%), including 1 in the group of patients who took ticagrelor and 11 in group of patients under clopidogrel (2.6% versus 6.7%, P = 0.55). Conclusions: Clopidogrel was ineffective in 19% of patients undergoing carotid stenting. Platelet count seemed to affect this phenomenon. In these patients, clopidogrel was effectively replaced by ticagrelor.Mazzaccaro D, Giannetta M, Ranucci M, Righini P, Di Dedda U, Baryshnikova E, Milani V, Nano G. 颈动脉支架置入术双联抗血小板治疗中的氯吡格雷抵抗与替格瑞洛替代方案[J]. 血管外科年鉴, 2023, 90:128-136. DOI: 10.1016/j.avsg.2022.09.063. 2022年10月19日提前在线发表. PMID: 36270550. 背景：接受颈动脉支架置入术并行双联抗血小板治疗的患者，若对氯吡格雷的药理作用产生抵抗，可能会增加围手术期神经事件的发生风险。本研究旨在描述一系列接受颈动脉支架置入术患者中的氯吡格雷抵抗现象。 方法：前瞻性收集2016年11月至2020年12月期间，因颈动脉显著狭窄接受颈动脉支架置入术，且接受乙酰水杨酸（阿司匹林）联合氯吡格雷双联抗血小板治疗的连续患者数据。排除已使用其他噻吩并吡啶类药物的患者。采用阻抗聚集试验评估抗血小板药物的疗效。本研究的主要终点为评估氯吡格雷抵抗的发生率，以及替格瑞洛作为替代治疗方案的有效性。以P值<0.05作为具有统计学显著性的判定标准。 结果：共计200例患者（其中女性80例，占比40%）因颈动脉狭窄接受支架置入术，其中94%为无症状患者。38例患者（占比19%）出现氯吡格雷抵抗，予替格瑞洛替代治疗（90mg，每日两次）后，聚集试验显示疗效达100%。血小板计数与氯吡格雷抵抗存在相关性（P = 0.001）。术后30天无支架血栓形成及重大出血事件发生；共计12/200例患者出现主要不良心血管事件，占比6%，其中替格瑞洛组1例，氯吡格雷组11例（2.6% vs 6.7%，P = 0.55）。 结论：19%接受颈动脉支架置入术的患者对氯吡格雷治疗无效。血小板计数似乎会影响该现象的发生。此类患者可通过替格瑞洛有效替代氯吡格雷治疗。