ACCP Cardiology PRN Journal Club. 24 May 2018

Transcription

1 ACCP Cardiology PRN Journal Club 24 May 2018

2 Mentor Bio Dr. James Coons is an associate professor at the University of Pittsburgh School of Pharmacy and clinical specialist at UPMC. Additionally, he is the PGY2 Cardiology Residency Program Director at UPMC. He completed his PharmD at the University of Pittsburgh, his PGY1 Pharmacy Practice residency at the University of Virginia Health System in Charlottesville, and his PGY2 in Cardiology at UPMC.

3 Presenter Bio Dr. Morgan Corkish is a PGY2 Cardiology Resident at the University of North Carolina Medical Center. She completed her PGY1 Pharmacy Practice Residency at the University of North Carolina Medical Center too. Morgan received her PharmD from the University of North Carolina Eshelman School of Pharmacy.

4 Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome (SECURE-PCI) Morgan E. Corkish, PharmD, BCPS PGY-2 Cardiology Pharmacy Resident UNC Medical Center Chapel Hill, NC

5 Disclosure Statement I have no financial relationships with commercial interests that pertain to the content presented in this program.

6 Background High intensity statin therapy is recommended for all patients with clinical ASCVD, regardless of baseline LDL levels The ideal timing of statin initiation after an acute coronary syndrome (ACS) event is unknown Mechanistic studies have suggested a potential benefit of statin loading doses in ACS through attenuation of inflammatory response Rosenson RS, et al. JAMA. 1998;279(20): Wang CY, et al. Trends Mol Med. 2008;14(1):37-44 Goff DC Jr, et al. Circulation Jun 24;129(25 Suppl 2):S49-73

7 Meta Analyses Evaluating Statin Loading Analysis of RCTs including 4,805 patients Statin loading prior to invasive procedures (CABG, PCI, non-cardiac) reduced postprocedure MIs Analysis of RCTs including 3,341 patients High dose vs. low/no dose statin pre-pci High dose statin reduced post-procedure MI and 30-day MACE Winchester DE, et al. J Am Coll Cardiol Sep 28;56(14): Patti G, et al. Circulation Apr 19;123(15):

8 Limitations of Previous Trials Small number of ACS patients included Majority of patients with stable CAD and elective PCI Low absolute number of clinical events Winchester DE, et al. J Am Coll Cardiol Sep 28;56(14): Patti G, et al. Circulation Apr 19;123(15):

9 SECURE-PCI Objective Assess the effect of loading doses of atorvastatin on clinical outcomes in patients with ACS and planned invasive management Berwanger O, et al. JAMA. 2018;319(13):

10 SECURE-PCI Study Overview Planned PCI 30 days Patients with ACS and invasive management planned within 7 days Randomization 1:1 Atorvastatin 80 mg x1 Placebo Atorvastatin 80 mg x1 Placebo Atorvastatin 40 mg daily ACS: Acute coronary syndrome NSTEMI: Non-ST-elevation myocardial infarction STEMI: ST-elevation myocardial infarction UA: Unstable angina PCI: Percutaneous coronary intervention Timing of loading dose 1: UA/NSTEMI: 2-12h before PCI STEMI: ASAP before PCI Timing of loading dose 2: 24h after PCI (or after 1 st dose if PCI not performed) Berwanger O, et al. JAMA. 2018;319(13):

11 SECURE-PCI Study Population Inclusion 18 years or older ACS with planned PCI < 7 days At least 2 of the following Angina-like chest pain EKG abnormalities on at least 2 contiguous leads Elevated cardiac biomarkers (CKMB and/or troponin) Exclusion History of advanced liver disease Use of any statin at maximum dose * within 24 hours of PCI Use of fibrates within the last 24 hours prior to using the study loading dose * Maximum doses of statins considered: atorvastatin 80 mg/d, rosuvastatin 40 mg/d, simvastatin 80 mg/d, pravastatin 40 mg/d, fluvastatin 80 mg/d Berwanger O, et al. JAMA. 2018;319(13):

12 SECURE-PCI Outcomes Primary Outcome Major adverse cardiovascular events (MACE) at 30 days Composite of all-cause mortality, acute MI, stroke, and unplanned coronary revascularization Secondary Outcomes Individual components of the primary outcome Cardiovascular death, stent thrombosis, and target vessel revascularization Assessed at 30 days Berwanger O, et al. JAMA. 2018;319(13):

13 SECURE-PCI Statistic Analysis Sample size of 4192 patients necessary for a power of 90% and a 2-tailed alpha = 0.05 Assumption was that approximately 70% of study population would undergo PCI, allowing for ~80% power for primary analysis in PCI-treated patients Main analysis performed in intention-to-treat population Sensitivity analyses performed for the primary outcome excluding patients who did not receive a loading dose, with clinical events before loading dose, and with clinical events before PCI Post hoc analyses to test interaction between PCI and ACS type (STEMI and NSTEMI) Berwanger O, et al. JAMA. 2018;319(13):

14 SECURE-PCI Baseline Characteristics Characteristics Atorvastatin (n = 2087) Placebo(n = 2104) Age, mean + SD, y Male 1581/2087 (75.8) 1525/2104 (72.5) Initial diagnosis STEMI NSTEMI UA 495/2031 (24.4) 1241/2031 (61.1) 295/2031 (14.5) 517/2049 (25.2) 1236/2049 (60.3) 296/2049 (14.4) Previous long-term use of statin therapy 608/2085 (29.2) 600/2102 (28.5) Medical history Hypertension Hyperlipidemia Diabetes Tobacco use Previous MI 1475/2085 (70.7) 755/2085 (36.2) 653/2084 (31.3) 564/2085 (27.1) 342/2085 (16.4) 1499/2102 (71.3) 764/2102 (36.3) 673/2102 (32.0) 618/2102 (29.4) 320/2102 (15.2) Berwanger O, et al. JAMA. 2018;319(13):

15 SECURE-PCI Baseline Characteristics Continued Characteristics Atorvastatin (n = 2087) Placebo(n = 2104) Initial treatment strategy PCI CABG surgery Medical management Time from randomization to study drug administration, median (IQR), h 1351/2085 (64.8) 162/2085 (7.8) 572/2085 (27.4) 1359/2102 (64.7) 171/2102 (8.1) 572/2102 (27.2) 0.1 (0-0.5) 0.2 (0-0.6) Time from hospital admission to PCI, median (IQR), h 20 (3-72) 19 (3-64) Reason PCI was not performed Clinical treatment CABG Not a final diagnosis of ACS Unknown Other medical therapy, % Aspirin Clopidogrel, ticagrelor, or prasugrel Beta blockers ACE inhibitors or ARAs 450/734 (61.3) 162/734 (22.1) 109/734 (14.9) 13/734 (1.8) 1880/2085 (90.2) 1775/2085 (85.1) 1606/2085 (77.0) 1484/2085 (71.2) 472/743 (63.5) 171/743 (23.0) 88/743 (11.8) 12/743 (1.6) 1883/2102 (89.6) 1766/2102 (84.0) 1599/2102 (76.1) 1444/2102 (68.7) Berwanger O, et al. JAMA. 2018;319(13):

16 SECURE-PCI Primary Endpoint Berwanger O, et al. JAMA. 2018;319(13):

17 SECURE-PCI Secondary Endpoints Characteristics, n (%) Atorvastatin (n = 2087) Placebo(n = 2104) P value Components of Primary Outcomes at 30 days Death Myocardial infarction Coronary revascularization Stroke 67/2087 (3.2) 61/2087 (2.9) 11/2087 (0.5) 10/2087 (0.5) Exploratory Analysis at 30 days in Subgroup of Patients Undergoing PCI MACE Death Myocardial infarction Coronary revascularization Stroke 81/1351 (6.0) 31/1351 (2.3) 48/1351 (3.6) 8/1351 (0.6) 4/1351 (0.3) Exploratory Analysis at 30 days in Subgroup of Patients Not Undergoing PCI MACE Death Myocardial infarction Coronary revascularization Stroke 49/734 (6.7) 36/734 (4.9) 13/734 (1.8) 3/734 (0.4) 6/734 (0.8) 70/2104 (3.3) 77/2104 (3.7) 14/2104 (0.7) 11/2104 (0.5) 112/1359 (8.2) 43/1359 (3.2) 70/1359 (5.2) 12/1359 (0.9) 8/1359 (0.6) 37/743 (5.0) 27/743 (3.6) 7/743 (0.9) 2/743 (0.3) 3/743 (0.4) Berwanger O, et al. JAMA. 2018;319(13):

18 SECURE-PCI Subgroup Analysis of Primary Outcome Berwanger O, et al. JAMA. 2018;319(13):

19 SECURE-PCI Authors Conclusions Loading doses of atorvastatin, compared with placebo, did not reduce the rate of MACE at 30 days in patients with ACS and planned invasive management Significant reduction in MACE among patients undergoing PCI suggests a benefit of loading doses in the periprocedural setting Mechanism of potential benefit is likely attributed to pleotropic effects that can start early after statin initiation Findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management Berwanger O, et al. JAMA. 2018;319(13):

20 SECURE-PCI Critique Strengths Multicenter, randomized study Pragmatic design Large sample size High risk ACS patient population Limitations Heterogeneous population 3% of included patients without confirmed diagnosis of ACS Low observed event rates Small difference in total drug exposure over 30 days between groups Maintenance dose atorvastatin 40 mg vs. 80 mg used Berwanger O, et al. JAMA. 2018;319(13):

21 Practice Implications They re Low Risk, so Why Not?

22 Acknowledgements Jim Coons, PharmD, BCPS-AQ Cardiology

23 Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome (SECURE-PCI) Morgan E. Corkish, PharmD, BCPS PGY-2 Cardiology Pharmacy Resident UNC Medical Center Chapel Hill, NC

24 Presenter Bio Dr. James Henderson is a PGY2 Cardiology Resident at the University of North Carolina Medical Center. He completed his PGY1 Pharmacy Practice Residency at Duke University Hospital. James received his PharmD from the University of Tennessee College of Pharmacy.

25 U N C H E A L T H C A R E S Y S T E M Ticagrelor vs Clopidogrel After Fibrinolytic Therapy in Patients With ST- Elevation Myocardial Infarction A Randomized Clinical Trial James Henderson, PharmD, BCPS University of North Carolina Medical Center May 24, 2018

26 Background ST-segment elevation myocardial infarctions (STEMIs) are a medical emergency requiring immediate medical evaluation and intervention Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for STEMI If PCI is not possible in a timely manner, many patients with STEMI receive fibrinolytic therapy as the initial reperfusion strategy Common fibrinolytic agents for STEMI Tenecteplase Alteplase Retaplase

27 Patel T, et al. Ann Trop Med Public Health 2013;6:14-9. Yusuf S, et al. N Engl J Med. 2001;345(7): Wiviott SD, et al. N Engl J Med. 2007;357(20): Wallentin L, et al. N Engl J Med 2009;361: Background (cont.) P2Y 12 -inhibitors (+ aspirin) are the backbone of therapy for patients who suffer from myocardial infarctions (MIs) Common Oral P2Y 12 -inhibitors Clopidogrel (CURE Trial) Prasugrel (TRITON-TIMI 38 Trial) Ticagrelor (PLATO Trial) Landmark Clinical Trials Excluded patients who received fibrinolytic therapy for the treatment of their MI

28 CLARITY Trial: Clopidogrel vs Placebo following Fibrinolytics Efficacy Outcomes Clopidogrel Placebo Odds Ratio (95% CI) P Value Primary Composite a, n (%) 262 (15.0) 377 (21.7) 0.64 (0.53 to 0.76) <0.001 TIMI flow grade 0-1, n (%) 192 (11.7) 301 (18.4) 0.59 (0.48 to 0.72) <0.001 Death, n (%) 45 (2.6) 38 (2.2) 1.17 (0.75 to 1.82) 0.49 Recurrent MI, n (%) 44 ( (3.6) 0.70 (0.47 to 1.04) 0.08 Safety Outcomes b Clopidogrel Placebo Odds Ratio (95% CI) P Value Major Bleeding, n (%) 33 (1.9) 30 (1.7) Minor Bleeding, n (%) 27 (1.6) 16 (0.9) Major or minor bleeding, n (%) 59 (3.4) 46 (2.7) a Composite of infarct-related artery occlusion on angiography, death, or recurrent MI before angiography b Outcomes at 30 days. Major and minor bleeding per the TIMI Bleeding Criteria Conclusions: In patients < 75 years old undergoing a STEMI who receive aspirin and fibrinolytic therapy, the addition of clopidogrel improves coronary patency and reduces ischemic complications No significant difference in rates of major or minor bleeding Sabatine M, et al. N Engl J Med 2005;352:

29 COMMIT Trial: Clopidogrel vs Placebo in STEMI patients Non-trial treatment during hospital stay Fibrinolytics before or after randomization, n (%) Clopidogrel (n=22,961) Placebo (n=22,891) 12,468 (54.3%) 12,499 (54.6%) Conclusions: Adding clopidogrel 75 mg daily to aspirin and other standard treatments (such as fibrinolytic therapy) safely reduces mortality and major vascular events in hospital Chen ZM, et al. Lancet 2005;366:

30 2016 ACC/AHA Guideline Focused Update Levine GN, et al. JACC 2016;68(10):

31 Ticagrelor vs. Clopidogrel for ACS (PLATO Study) In patients with or with STEMI, ticagrelor reduced the composite of cardiovascular death, MI, and stroke without an increased rate of overall major bleeding Ticagrelor demonstrated significantly more fatal intracranial bleeding, and non-cabg related major bleeding (TIMI and PLATO criteria) Exclusion Criteria: Fibrinolytic therapy within 24 hours before randomization Wallentin L, et al. N Engl J Med 2009;361:

32 In patients with ST-elevation myocardial infarction treated with fibrinolytic therapy, is ticagrelor noninferior to clopidogrel with respect to thrombolysis in myocardial infarction major bleeding? Berwanger O, et al. JAMA Cardiol 2018;3(5):

33 Methods: Design Design Countries Randomization and Study Treatment TREAT Trial Phase 3, international, multicenter, randomized, open-label study with a blinded outcome assessment that involved Argentina, Australia, Brazil, Canada, China, Colombia, New Zealand, Peru, Russia, and Ukraine Group 1: Ticagrelor 180 mg loading dose, then 90 mg BID Group 2: Clopidogrel mg loading dose, then 75 mg daily All patients: Aspirin loading dose, then mg daily Other evidence based medicines (at treating physicians discretion) Patients were followed for 30 days following randomization Berwanger O, et al. JAMA Cardiol 2018;3(5):

34 Methods: Inclusion/Exclusion Criteria Age <75 years Inclusion Criteria Received fibrinolytic therapy for STEMI Presentation within 24 hours from symptom onset Exclusion Criteria Contraindication to clopidogrel Use of oral anticoagulation Increased risk of bradycardia Concomitant therapy with a strong cytochrome P-450 3A inhibitor or inducer Berwanger O, et al. JAMA Cardiol 2018;3(5):

35 Methods: Endpoints Primary Safety Outcome Secondary Safety Outcomes Exploratory Secondary Efficacy Outcomes TREAT Trial Major bleeding Thrombolysis in Myocardial Infarction (TIMI) definition Major or minor bleeding: PLATO trial definition Bleeding Academic Research Consortium (BARC) definition Clinically relevant nonmajor bleeding or minor bleeding TIMI definition Composite: Death from vascular causes, MI, or stroke Composite: Death from vascular causes, MI, stroke, recurrent ischemia, transient ischemic attack (TIA), or other arterial thrombotic events Individual Composite components All-cause mortality at 30-days Berwanger O, et al. JAMA Cardiol 2018;3(5):

36 Methods: Statistical Analysis Concern for major bleeding events was the main driver of the primary outcome of the TREAT Trial Projected TIMI major bleeding rates at 30 days were approximately 1.2% Based on previous trials of ticagrelor in patients with STEMI undergoing PCI An increase in bleeding of < 1.0% was considered to meet criteria for noninferioirity To achieve 90% statistical power with a margin of 1.0% and a 1-sided alpha of 2.5%, each group required a minimum of 1897 patients Prespecified safety and efficacy analysis were performed in subgroups: Age, sex, Killip risk score, diabetes mellitus, time from start of index event to randomization, aspirin, fibrinolytic choice, and use of clopidogrel prior to randomization Berwanger O, et al. JAMA Cardiol 2018;3(5):

37 Results: Patient Randomization Period of Enrollment: November 2015-November 2017 Randomized in a 1:1 ratio Randomization typically occurred several hours after onset of symptoms Median 2.6 hours (IQR ) from chest pain to fibrinolytic therapy Median 11.4 hours (IQR hours) after fibrinolytic therapy to randomization Overall very low rate of exclusion in this trial (< 1% in both arms) Berwanger O, et al. JAMA Cardiol 2018;3(5):

38 Results: Significant Baseline Characteristics Characteristic Ticagrelor (n=1913) No./Total No.(%) Clopidogrel (n=1886) No./Total No.(%) Age, median (IQR), y 59 ( ) 58.8 ( ) Female 433/1913 (22.6) 438/1886 (23.2) Median body weight, mean (IQR), kg 76.5 ( ) 77.0 ( ) Race/ethnicity White Black Asian Cardiovascularrisk factors Habitual smoker Hypertension Dyslipidemia Diabetes Other medical history MI Stroke Atrial Fibrillation Berwanger O, et al. JAMA Cardiol 2018;3(5): /1913 (57.5) 73/1913 (3.8) 631/1913 (33.0) 881/1913 (46.1) 1072/1913 (56.0) 524/1913 (27.4) 332/1913 (17.4) 178/1913 (9.3) 83/1913 (4.3) 21/1913 (1.1) 1077/1886 (57.1) 61/1886 (3.2) 639/1886 (33.9) 878/1886 (46.6) 1071/1886 (56.8) 525/1886 (27.8) 303/1886 (16.1) 150/1886 (8.0) 84/1886 (4.5) 24/1886 (1.3)

39 Results: Concomitant Medications Medication Ticagrelor (n=1913) No./Total No.(%) Clopidogrel (n=1886) No./Total No.(%) Aspirin 1890/1913 (98.8) 1865/1886 (98.9) Unfractionated heparin 758/1913 (39.6) 744/1886 (39.4) Low-molecular-weight heparin 1322/1913 (69.1) 1297/1886 (68.8) Glycoprotein IIb/IIIa inhibitor 101/1913 (5.3) 92/1886 (4.9) Beta-blocker 1410/1913 (73.7) 1396/1913 (74.0) ACE-inhibitor 1132/1913 (59.2) 1113/1886 (59.0) Angiotensin-II receptor blocker 202/1913 (10.6) 172/1886 (9.1) Statin 1780/1913 (93.0) 1762/1886 (93.4) Berwanger O, et al. JAMA Cardiol 2018;3(5): Sabatine M, et al. N Engl J Med 2005;352:

40 Results: Fibrinolytic Therapy Fibrinolytic Ticagrelor (n=1913) No./Total No.(%) Clopidogrel (n=1886) No./Total No.(%) Clopidogrel (n=1752) (CLARITY Trial) Tenecteplase 757/1911 (39.6) 750/1884 (39.8) 838 (47.8) Alteplase 377/1911 (19.7) 362/1884 (19.2) 209 (9.1) Prourokinase 322/1911 (16.8) 313/1884 (16.6) -- Urokinase 131/1911 (6.9) 135/1884 (7.2) -- Streptokinase 109/1911 (5.7) 106/1884 (5.6) 542 (30.9) Other 81/1911 (4.2) 77/1884 (4.1) -- Berwanger O, et al. JAMA Cardiol 2018;3(5):

41 Results: Safety Endpoints Outcomes Ticagrelor, No. (%) (n=1913) Clopidogrel, No. (%) (n=1886) Difference in Percentage Points (95% CI) Major bleeding (TIMI) 14 (0.73) 13 (0.69) 0.04 (-0.49 to 0.58) PLATO major bleeding 23 (1.20) 26 (1.38) (-0.89 to 0.54) BARC type 3-5 bleeding 23 (1.20) 26 (1.38) (-0.89 to 0.54) a P Values based on noninferiority test a Outcomes Ticagrelor, No. (%) (n=1913) Clopidogrel, No. (%) (n=1886) Difference in Percentage Points (95% CI) P Value Minimal bleeding (PLATO) 62 (3.24) 38 (2.01) 1.23 (0.21 to 2.24) 0.02 Any bleeding 103 (5.38) 72 (3.82) 1.57 (0.24 to 2.90) 0.02 Intracranial hemorrhage 8 (0.42) 7 (0.37) 0.05 (-0.35 to 0.45) 0.82 Berwanger O, et al. JAMA Cardiol 2018;3(5):

42 Results: Efficacy Endpoints Outcomes Ticagrelor, No. (%) (n=1913) Clopidogrel, No. (%) (n=1886) Difference in Percentage Points (95% CI) Death from vascular causes, MI, or stroke 76 (4.0) 82 (4.3) 0.91 ( ) P Value 0.57 Death from vascular causes, MI, or nonhemorrhagic stroke Death from vascular causes, MI, stroke, severe recurrent ischemia, recurrent ischemia, TIA, or other arterial thrombotic event 70 (3.7) 77 (4.1) 0.90 ( ) (5.1) 95 (5.0) 1.02 ( ) 0.90 No difference in any of the components of the composite outcomes Berwanger O, et al. JAMA Cardiol 2018;3(5):

43 Discussion Rates of minimal bleeding (PLATO criteria) and total bleeding were higher with ticagrelor than clopidogrel No difference in intracranial hemorrhage Results of this trial were similar to smaller previous trials Dehghani et al. (n=144) Clopidogrel vs. ticagrelor in patients undergoing PCI post-reperfusion with tenactaplase SAMPA Trial (n=50) Ticagrelor vs. prasugrel in patients with STEMI post-fibrinolytic therapy Prior to randomization, that vast majority of patients received clopidogrel Berwanger O, et al. JAMA Cardiol 2018;3(5): Dehghani P, et al. Am Heart J. 2017;192: Guimaraes LFC, et al. Int J Cardiol. 2017;230:

44 Clopidogrel Use Prerandomization Clopidogrel administration before randomization, No/total No. (%) Ticagrelor (n=1913) Clopidogrel (n=1886) None or less than 300 mg 195/1898 (10.3) 202/1876 (10.8) 300 mg 1652/1898 (87.0) 1614/1876 (86.0) More than 300 mg 51/1898 (2.7) 60/1876 (3.2) Approximately 50% of patient in the PLATO trial also received clopidogrel prior to randomization Berwanger O, et al. JAMA Cardiol 2018;3(5):

45 Audience Question #1 What strategy does your institution use to transition patients from clopidogrel to ticagrelor? Response (please include): Strength of ticagrelor (90 or 180 mg) Timing post-clopidogrel dose (12 hours, 24 hours, do not account for timing of clopidogrel)

46 Audience Question #2 What strategy does your institution use to transition patients from ticagrelor to clopidogrel? Response (please include): Strength of clopidogrel (75, 150, 300, 600 mg) Timing post-ticagrelor dose (12 hours, 24 hours, do not account for timing of ticagrelor)

47 Limitations Major cardiovascular events were similar between groups, but at a low overall event rate Not statistically powered to assess efficacy of clopidogrel vs. ticagrelor Median time of thrombolytic administration to randomization was about 11 hours Similar to previous smaller trials Tenecteplase terminal half-life: minutes Subgroup of patients who received P2Y 12 within 4 hours of fibrinolytics had more TIMI major bleeding, but this was similar in both groups Major TIMI Bleeding-Sensitivity analysis Ticagrelor Clopidogrel Hazard Ratio P Value Per protocol: Time from symptom to randomization <24 hours, No/Tot No. (%) Time from fibrinolytic to randomization within 4 hours, No/Tot No. (%) 14/1801 (0.78) 12/1764 (0.68) 1.14 (0.53 to 2.47) /327 (1.53) 4/329 (1.22) 1.26 (0.34 to 4.68) 0.73 Berwanger O, et al. JAMA Cardiol 2018;3(5):

48 Conclusions Authors In patients younger than 75 years with STEMI, delayed administration of ticagrelor after fibrinolytic therapy was noninferior to clopidogrel for TIMI major bleeding at 30 days Personal In STEMI patients who present from an OSH after receiving fibrinolytic therapy, it is reasonable to consider ticagrelor over clopidogrel for both acute and chronic medical management of their acute coronary syndrome Regardless of whether the patient received a dose of clopidogrel at the OSH Berwanger O, et al. JAMA Cardiol 2018;3(5):

49 U N C H E A L T H C A R E S Y S T E M Ticagrelor vs Clopidogrel After Fibrinolytic Therapy in Patients With ST- Elevation Myocardial Infarction A Randomized Clinical Trial James Henderson, PharmD, BCPS University of North Carolina Medical Center May 24, 2018

50 Save The Date June 14 th at 3P EST/2P CST/1P MST/Noon PST Articles: A Cluster-Randomized Trial of Blood- Pressure Reduction in Black Barbershops (NEJM) BARBER-1 Study - Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men (Arch Intern Med) Presenters: Kody Merwine (UK) Liz Sulaica (UK) Mentor: Rob Hough (West Palm Beach VAMC)