aspirin resistance. clinical questions how do we define aspirin resistance? is this concept...
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Aspirin Resistance
Clinical Questions
How do we define aspirin resistance? Is this concept clinically relevant? Why aren’t we testing for it?
Aspirin Basics
Antithrombotic Trialists’ Collaboration Major meta-analysis reporting 25% reduction in
significant vascular events as secondary prevention Prevents at least 10-20 fatal and nonfatal vascular
events for every 1000 patients treated for one year. American Heart Association recommends
prophylaxis for: 10yr risk of CHD >10% Pharmacology
Consistent absorption via passive diffusion in GI tract with peak plasma levels in 30min
Enteric coated peak in 3-4 hours with variable bioavailability
Platelet Basics
Adhesion: Platelet membrane receptors bind to endothelium and subendothelium at sites of damageActivation: Transmembrane signaling increases surface receptors, granule release, and exposure of membrane phospholipidAggregation: Procoagulant surface of the membrane serves as basis for coagulation cascade, amplification of platelet response, and production of fibrin.
Wide acceptance that platelet activity plays a major role in atherothrombosis
Aspirin Inhibition of Platelets
Aspirin inhibits platelet cyclooxygenase (COX)-1 thereby preventing formation of thromboxane A2 (TxA2), a potent aggregating and vasocontrictor agent.Acetylation serine 529 of COX-1Platelets – anucleate and unable to
regenerate COX-1• Platelet lifespan 7-10 days • Maturation time from megakaryocytes: 4 days
NSAID Mechanism
Definition of “Aspirin Resistance” Clinical failure of prevention Biochemical resistance Laboratory Phenomenon
Or….
Patient just doesn’twant to take it.
Clinical “Aspirin Resistance”
Perhaps more appropriate term would be “treatment failure”
Probabilities Game Failure is to be expected in the
treatment/prevention of any multi-factorial disease process
Theories of Biochemical Resistance Endothelial cells recover COX-1 activity
shortly after aspirin exposure Role of COX-2 in thrombotic process Thromboxane-independent methods of
platelet activation Genetic polymorphisms
GP IIb-IIIa receptorPlatelet alloantigen 2 (PlA2)
Laboratory Definition
Bleeding time Aggregometry Platelet function analyzer (PFA-100) Platelet Release Products VerifyNow Aspirin Platelet Membrane Expression
Bleeding Time
Should not be used Low Sensitivity
Invasive Poorly reproducible Multiple Variables
• Platelet function• Platelet count• Plasma factors• Red Blood Cells• Skin trophism
Aggregometry
Light Transmission Aggregometry Measures light transmission through a platelet
suspension in response to agonist (arachodonic acid or ADP)
Reports: % residual platelet function Clinical association with vascular events Historic Reference Standard
time-consuming and user-dependent limited availability and requires rapid analysis lack of standardization
Aggregometry
Whole Blood Aggegrometry Measures electrical impedance between two
electrodes immersed in whole blood 5min after addition of a platelet agonist
Reports: impedance in Ω Easy, sensitive, reproducible
Large sample of blood required Long preparation time Expensive
Platelet Function Analyzer-100
Reports: closure time (<193s) No association with vascular events Point-of-Care test
Must test within 4hrs of blood collection Dependent on hematocrit and vWF
Anticoagulated blood is aspirated through a capillary and a 150μm aperture coated with collagen and ADP or epinephrine. Measures time needed until blood flow interruption is recorded.
Platelet Release Products
Serum TXA2
Urinary 11-dehydrothromboxane B2
Directly dependent on aspirin’s effect on COX-1 inhibition
Simple and correlated with clinical events Indirect measurement Not specific to platelets Urinary test dependent on renal function
VerfiyNow Aspirin
Turbidometric-based optical system that measures agglutination of fibrinogen-coated beads by platelets stimulated in citrated whole blood.
Reports: Aspirin Reaction Units Clinical association with vascular events Point-of-care test
Major limitation relates to the diagnostic criteria set for definition of aspirin resistance
Compared to optical aggregometry with epinephrine after one 325mg dose of aspirin
Platelet Membrane Expression
Platelet bound P-selectin Soluble plasma P-selectin Platelet-leukocyte aggregates Platelet-derived microparticles
Flow cytometry allows for the evaluation of platelet reactivity and in vivo activation. However, these techniques require sophisticated and expensive instruments.
A comparison of six major platelet function tests to determine the prevalence of aspirin resistance in patients with stable coronary artery disease.
Marie Lordkipanidze, Chantal Pharand, Erick Shampaert, Jacques Turgeon, Donald Palisaitis, and Jean G. Diodati.
European Heart Journal in June 2007
Study Design
201 patients with stable CAD on daily aspirin therapy (>80mg) Consecutive patients diagnosed with CAD Montreal, Canada Sample collection: morning urine and blood
Exclusions: ACS or revascularization within 6 months Concurrent use of NSAIDs, clopidogrel,
dipyridamole, warfarin, acenocoumarol Major surgery within 1 month of enrollment Thrombocytopenia, Hct <25% Dialysis
Platelet Function Tests
LTA with arachidonic acid LTA after adenosine diphosphate Whole blood aggregometry PFA-100 VerifyNow Aspirin Urinary 11-dehydrothrombaxane B2
Patient Data
155 Male (71%) Mean Age: 66.5 ± 10.4 All with aspirin ≥ 1 month
80mg – 110 patients81mg – 10 patients162.5mg – 1 patient325mg – 79 patients1300mg – 1 patient
Results
κ Statistic Agreement0 - 0.2 Slight0.2 - 0.4 Fair0.4 - 0.6 Moderate0.6 - 0.8 Substantial
Prevalence of Resistance
Discussion
Overall, poor correlation between different platelet function tests
“Aspirin resistance” based on arbitrary, clinically non-validated cut-off values.
“We believe the non-standardized use of these assays and the absence of a formal definition explains much of the disparity reported in the literature in regards to the prevalance of aspirin resistance.”
Perhaps it is more important to determine cut-off values with the intent of predicting clinical outcomes instead of focusing on a “gold standard” test.
Clinical Confounders
Drug Interactions: NSAIDs
may occupy nearby catalytic site
Block access of aspirin to serine 529
Ibuprofen, Indomethacin
PPIs? ACE Inhibitors?
Comorbid Conditions Isoprostanes
prostaglandin F2-like compounds
Produced from arachidonic acid in a non-COX process
Amplify platelet response Smoking Diabetes Hyperlipidemia, Unstable Angina
Variable Aspirin Response
Most studies have not evaluated aspirin resistance over time
Cohort study out of the University of Chicago published in 1994 Secondary prevention in 306 patients with
history of ischemic stroke Repeated assessments of aspirin resistance
over a 6 month interval Light Transmission Aggregometry 32.7% of patients did not maintain complete
inhibition with repeated testing Reassessment of fixed-dose regimens?
Patient Compliance
Schwartz, et al. studied tested 190 patients using LTA and found 9% resistance Repeat testing after directly observed therapy
in all 9% Nonresponders responders
Tantry, et al. studied 223 patients with CHD All but 7 patients had aspirin response via LTA Those 7 patients were interviewed again and
admitted to noncompliance
No laboratory testing to monitor for clinical adherence
Working Group on Aspirin Resistance in 2005
“Other than in research trials, it is not currently appropriate to test for aspirin
‘resistance’ in patients or change therapy based on these tests.”
Summary
“Aspirin Resistance,” from biochemical and lab perspective, probably has clinical relevance
There continues to be significant investigation and discovery regarding aspirin therapy
Clinical application is on the distant horizon.
Consider alternatives to NSAIDs Focus on patient compliance
seek to dispel myths assess for and control side effects.
References Airee, et al. Aspirin resistance: disparities and clinical
implications. Pharmacotherapy 2008; 28(9): 999-1018. Antithrombotic Trialists Collaboration. Collaborative meta-
analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324: 71-86.
Cattaneo, M. Resistanc to antiplatelet drugs: molecular mechanisms and laboratory detection. J Thromb Haemost 2007; 5 (Suppl 1): 230-7.
Christiaens, et al. Major clinical vascular events and aspirin-resistance status determined by the PFA-100 method among patients with stable coronary artery disease: a prospective study. Blood Coag and Fib 2008. 19(3): 235-9.
Gasparyan, et al. The role of aspirin in cardiovascular prevention. J Am Coll Cardiol 2008. 51; 19: 1829-43.
Gum, et al. A prospective, blinded determination of the natural history of aspirin resistance among stable patients with cardiovascular disease. J Am Coll Cardiol 2003; 41(6): 961-5.
Helgason, et al. Development of aspirin resistance in persons with previous ischemic stroke. Stroke 1994. 25: 2331-2336
Lordkipanidze, et al. A comparison of six major platelet function tests to determine the prevalence of aspirin resistance in patients with stable coronary artery disease. Euro Heart J 2007; 28(14): 1673-5.
MacDonald, et al. Effect of ibuprofen on the cardioprotective effect of aspirin. Lancet 2003. 15; 361(9357): 573-4.
Michelson, et al. Aspirin resistance: position paper of the Working Group on Aspirin Resistance. J Thromb Haemost 2005; 3: 1309-11.
Patrono, et al. Low-dose aspirin for prevention of atherothrombosis. N Engl J Med 2005. 353; 22: 2373-83.
Sanderson, et al. Narrative review: aspirin resistance and its clinical implications. Annals of Int Med 2005. 142; 5: 370-80.
Viola et al. Aspirin resistance: is this term meaningful? Curr Opin Hematol 2006. 13: 331-336.