Abstract Background Elderly patients display higher on clopidogrel platelet reactivity as compared to younger patients. Treatment with prasugrel 5 mg has been shown to provide more predictable and ...homogenous antiplatelet effect, as compared to clopidogrel, suggesting the possibility of reducing ischemic events after an acute coronary syndrome (ACS) without increasing bleeding. Study design The Elderly-ACS 2 study is a multicenter, randomized, parallel-group, open-label trial designed to demonstrate the superiority of a strategy of dual antiplatelet treatment using a reduced 5 mg daily dose of prasugrel over a standard strategy with a daily clopidogrel dose of 75 mg in patients >74 years of age with ACS (either ST- or non ST-elevation myocardial infarction) undergoing early percutaneous revascularization. The primary endpoint is the composite of all-cause mortality, myocardial re-infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year. Taking advantage of the planned size of 2000 patients, the secondary objective is to assess the prognostic impact of selected pre-randomization variables (age, sex, diabetic status, serum creatinine level, ECG changes, abnormal troponin levels, basal and residual SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery SYNTAX score). Conclusion The Elderly-ACS 2 study is a multicenter, randomized trial comparing a strategy of dual antiplatelet therapy with a reduced dose of prasugrel with a standard dose of clopidogrel in elderly patients with ACS undergoing percutaneous revascularization. (The Elderly ACS 2 trial: NCT01777503 )
BACKGROUND—Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome (ACS), and display higher on-clopidogrel platelet reactivity as compared ...to younger patients. Prasugrel 5 mg provides more predictable platelet inhibition, as compared to clopidogrel, in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding.
METHODS—In a multicenter, randomized, open-label, blinded-endpoint trial, we compared a once daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years with ACS undergoing percutaneous coronary intervention (PCI). The primary endpoint was the composite of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg.
RESULTS—Enrolment was interrupted, according to pre-specified criteria, after a planned interim analysis, when 1443 patients (40% women, mean age 80 years) had been enrolled, with a median follow-up of 12 months, due to futility for efficacy. The primary endpoint occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (HR 1.007, 95% CI, 0.78-1.30; P =0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel vs 1.9% with clopidogrel (OR 0.36, C.I. 0.13-1.00, p=0.06). Bleeding Academic Research Consortium types ≥2 were 4.1% with prasugrel vs 2.7% with clopidogrel (OR 1.52, C.I. 0.85-3.16, P= 0.18).
CONCLUSIONS—The present study in elderly ACS patients showed no difference in the primary endpoint between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in the light of premature termination of the trial.
CLINICAL TRIAL REGISTRATION—URLhttps://clinicaltrials.gov/ Unique IdentifierNCT01777503
Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter ...among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk.
All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission.
We included in our analysis 1364 patients, divided in quartiles of Hb values (<12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR95%CI = 0.76 0.59-0.97, p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR95%CI = 1.22 0.41-3.6, p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients.
Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.
Biogas produced from anaerobic digestion of organic materials is emerging as a renewable energy source. Unfortunately, the large quantities of CO2 contained in the raw biogas greatly decreases its ...calorific value, thus efficient CO2 separation is needed to upgrade biogas to biomethane. Several technologies, based on physical or chemical sorption of CO2, are already available but they suffer of some drawbacks, primarily related to their negative impact on the environment and/or high energy requirements. Development of alternative green biogas upgrading technologies is therefore needed, and research is growing exponentially in this field. As a consequence, a frequent assessment of the state of the art of these rapidly evolving technologies is required.
This review summarizes the latest advances on emerging strategies for biogas upgrading based on unconventional organic solvents such as ionic liquids and deep eutectic solvents and clathrate/semi clathrate hydrates, for which low cost, ease of operation and environmental sustainability represent attractive advantages over conventional technologies. In particular, the present work is focused on the performance of these CO2 sorbent systems in terms of CO2/CH4 selectivity rather than CO2 absorption capacity. Indeed, CO2/CH4 selectivity is the most important parameter for evaluating the suitability of a sorbent for practical applications, as high selectivity means negligible CH4 losses. The scientific results published in the last few years have been collected and discussed to serve as a guide for researchers in choosing the optimal technology and operating conditions in the perspective of efficient and environmentally friendly separation of CO2 from biogas. Ionic liquids and deep eutectic solvents are excellent candidates for biogas upgrading, especially in the form of hybrid systems, which show the best performance in terms of selectivity. Similarly, biogas upgrading via clathrate hydrates can be considered efficient, environmentally friendly and cost-effective. However, some drawbacks still need to be addressed.
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