Incidence of Device-Related Thrombosis in Watchman Patients Undergoing a Genotype-Guided Antithrombotic Strategy.

Abstract

OBJECTIVES:

This study sought to report the incidence of device-related thrombosis (DRT) and thromboembolic (TE) events when an alternative to clopidogrel is prescribed in loss-of-function (LOF) allele carriers of the cytochrome P450 2C19 (CYP2C19) gene.

BACKGROUND:

LOF polymorphisms of the CYP2C19 gene are associated with reduced hepatic bioactivation of clopidogrel.

METHODS:

A total of 1,002 Watchman patients were included. Six hundred forty-five patients underwent CYP2C19 genetic testing; among patients with clopidogrel resistance, clopidogrel was replaced by either prasugrel (pilot cohort) or half dose direct oral anticoagulant ([DOAC]/Group 1), both in combination with aspirin. We compared the incidence of DRT/TE events among genotyped patients and a control group which received standard dual antiplatelet therapy (DAPT) (Group 2; n = 357). All reported events occurred during a timeframe between 45- and 180-day follow-up transesophageal echocardiograms, when the 2 different antithrombotic strategies (genotype-guided vs standard DAPT) were adopted.

RESULTS:

In the pilot cohort (n = 244), bleeding events occurred in 10.2% of patients who received aspirin plus prasugrel, leading to early discontinuation of the prasugrel-based protocol. DOAC Group 1 patients (n = 401), 25.7% were reduced metabolizers, and clopidogrel was replaced by half dose direct oral anticoagulant. DRT was documented in 1 (0.2%) patient of Group 1 and 7 (1.96%) patients of Group 2 (log-rank P = 0.021). The composite endpoint of DRT/TE events was significantly lower among patients receiving a genotype-guided antithrombotic strategy (0.75% vs 3.10%; log-rank P = 0.017).

CONCLUSIONS:

In Watchman patients, a genotype-based antithrombotic strategy with aspirin plus half dose DOAC in reduced clopidogrel metabolizers was superior to standard DAPT with respect to DRT/TE events.

• Authors: Domenico G Della Rocca, Rodney P Horton, Luigi Di Biase, Carola Gianni, Chintan Trivedi, Sanghamitra Mohanty, Alisara Anannab, Michele Magnocavallo, Qiong Chen, Nicola Tarantino, Mohamed Bassiouny, Carlo Lavalle, Veronica N Natale, Giovanni B Forleo, Armando Del Prete, Christoffel Johannes Van Niekerk, Amin Al-Ahmad, J David Burkhardt, G Joseph Gallinghouse, Javier E Sanchez, Dhanunjaya Lakkireddy, Douglas N Gibson, Andrea Natale
• Journal: JACC. Clinical electrophysiology (JACC Clin Electrophysiol) Vol. 7 Issue 12 Pg. 1533-1543 (12 2021) ISSN: 2405-5018 [Electronic] United States
• PMID: 34217665 (Publication Type: Journal Article)
• Copyright: Copyright © 2021. Published by Elsevier Inc.

Chemical References

• Fibrinolytic Agents
• Clopidogrel

Topics

• Clopidogrel (adverse effects)
• Fibrinolytic Agents
• Genotype
• Humans
• Incidence
• Thrombosis (drug therapy, epidemiology, genetics)