Treatment with dual antiplatelet therapy after an acute coronary event may often be tailor-made for the patient

Optimal platelet inhibition is one of the most important goals in the acute treatment of segment (ST)-elevation myocardial infarction (STEMI) patients.1 Opioids are widely used in daily practice but delay the intestinal drug absorption of P2Y12 inhibitors.2 Moreover, nausea and vomiting are more frequently seen in patients receiving opioids,2,3 which further may reduce the uptake of oral platelet inhibitors. Tavanier and co-workers from the Netherlands randomized 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to i.v. acetaminophen (paracetamol) or i.v. fentanyl in the ambulance. The authors concluded that i.v. acetaminophen in comparison with i.v. fentanyl was not associated with significantly lower platelet reactivity in STEMI patients, but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief. There are data suggesting that ticagrelor may possess antibacterial activity.4,5 In a Danish observational cohort study with 26 606 patients, Butt and co-workers investigated the 1-year risks of Staphylococcus aureus bacteremia (SAB), sepsis, and pneumonia in patients who underwent PCI and were treated with ticagrelor vs. clopidogrel. They report that treatment with ticagrelor was associated with a significantly lower 1-year risk of SAB, sepsis, and pneumonia compared with clopidogrel. Dual antiplatelet therapy (DAPT) with a P2Y 12 inhibitor on top of aspirin is the cornerstone of therapy after acute coronary syndromes (ACSs). Nonetheless, the safest and most efficacious P2Y 12 for older patients who are at both high ischaemic and high bleeding risk remains uncertain.6 In a meta-analysis consisting of seven studies (14 485 patient-years), the authors examined the effect of available P2Y12 inhibitors on ischaemic and bleeding endpoints in older adults with ACS. They concluded that among older subjects with ACS, DAPT should be balanced upon ischaemic and bleeding risks as prasugrel is associated with the highest probability of reduction of ischaemic events and clopidogrel with bleedings. Ticagrelor had highest [surface under the cumulative ranking curve analysis (SUCRA)] for stent thrombosis reduction but seems suboptimal in older adults. In a multicentre study led by Dr Valgimigli, the authors sought to assess whether the bleeding risk prediction offered by the PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti Platelet Therapy (PRECISE-DAPT)7–9 remains valid among patients receiving ticagrelor monotherapy from 1 month onwards after coronary stenting instead of standard DAPT and having or not having centrally adjudicated bleeding endpoints. The PRECISE-DAPT was calculated in 14 928 and 7134 patients from the GLOBAL LEADERS and GLOBAL LEADERS Adjudication Sub-Study (GLASSY) trials. They concluded that the PRECISE-DAPT offers a prediction model that proved similarly effective to predict clinically relevant bleeding among patients on ticagrelor monotherapy from 1 month after coronary stenting compared with standard DAPT and appears to be unaffected by the presence or absence of adjudicated bleeding endpoints. Serruys and co-workers aimed to investigate the efficacy and safety of ticagrelor monotherapy in patients undergoing PCI stratified according to the baseline white blood cell (WBC) count. These data also originate from the GLOBAL LEADERS trial. The authors reported that increased WBC counts, which may reflect degree of inflammation, at the time of index procedure, may attenuate the anti-ischaemic benefits of ticagrelor monotherapy observed in patients with lower WBC counts. In a study from Korea, Hong et al. aimed to evaluate the effect of ticagrelor monotherapy after short-term DAPT after PCI on mortality. They made a systematic review and meta-analysis searching for ticagrelor monotherapy after short-term DAPT comparing conventional DAPT in patients who underwent PCI. Three randomized trials encompassing 26 143 patients were included. The group concluded that ticagrelor monotherapy after short-term DAPT of 1 to 3 months was associated with decreased all-cause mortality and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding not offset by increase of cardiac death, ischaemic stroke, acute myocardial infarction, and stent thrombosis. The optimal treatment period with DAPT is still to be determined.10–13 In a study from Italy, Porto and co-workers compared the safety and efficacy of very short (≤3 months), short (6 months), standard (12 months), and extended (>12 months) DAPT, and subsequent monotherapies, after DES. They used 22 RCT (n = 110 059 patients/year) in a Bayesian network meta-analysis. The authors report that the efficacy of short and very short is comparable with that of standard DAPT after DES implantation, whereas extended DAPT reduces the MI rate. Very short DAPT reduces haemorrhagic events and, followed by a P2Y 12 inhibitor monotherapy, may be preferred in order to pursue a trade-off between major bleeding and ischaemia. This paper is accompanied by an editorial by Dr Siontis from Switzerland. Resistant hypertension (RH) accounts for 10–15% of the hypertensive population and represents an important risk factor for end-organ damage, cardiovascular complications, and death.14,15@ Hypertension and RH are linked to deleterious vascular remodelling. Ruilope and co-workers from Spain aimed to evaluate matrix metalloproteinase (MMP-9) activity as a predictor of responsiveness to treatment with spironolactone in RH. The correct identification of patients likely to respond to spironolactone would minimize therapy modifications and would help to achieve BP targets in the early stages of systemic damage. The authors propose active MMP-9 as a feasible biomarker to identify RH patients who will not respond to spironolactone. Combining MMP-9 activity with classical arterial stiffness parameters improves the prediction of the clinical response to spironolactone and might contribute to guide the most adequate pharmacological management of patients with RH. Adults with transposition of the great arteries (TGA) after an atrial switch operation (AtrSO) are at risk of gradual deterioration of systemic right ventricular (RV) function, congestive heart failure, and premature mortality.16 Heart failure is the main threat to long-term health in adults with TGA corrected by an AtrSO. The current guidelines refrain from recommending heart failure medication in TGA-AtrSO, as there are insufficient data to support the hypothesis that it is beneficial. In a study from the Netherlands, Woudstra et al. aimed to evaluate medication use in TGA-AtrSO patients and examine the association of use of renin–angiotensin–aldosteron system (RAAS) inhibitors and β-blockers with long-term survival. They identified 150 TGA-AtrSO patients in a registry cohort and report that the use of heart failure medication is high in TGA-AtrSO patients, although evidence of its benefit is limited. This study showed lower risk of mortality with use of RAAS inhibitors and β-blockers in symptomatic patients only. These findings can direct future guidelines, supporting the use of RAAS inhibitors and β-blockers in symptomatic, but not asymptomatic, patients. There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite the diverse availability, interpretation, and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. We are very pleased to publish an ESC position paper from the Working Group of Cardiovascular Pharmacotherapy entitled ‘The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy’. We also publish a current opinion from the same group. This viewpoint supplements the working group position paper on cardiovascular pharmacogenomics to address these important themes. Conflict of interest: None declared.