Disertasi

Peran Faktor Genetik dan Epigenetik Terkait ResistensiKlopidogrel terhadap Kejadian Kardiovaskular Mayor padaPasien Sindrom Koroner Akut Pasca Intervensi Koroner Perkutan = The Role of Genetic and Epigenetic Factors Related toClopidogrel Resistance in Major Adverse Cardiovascular Eventson Acute Coronary Syndrome Patients after PercutaneousCoronary Intervention.

Sindrom koroner akut (SKA) merupakan masalah kesehatan nasional karena tingginyaangka morbiditas dan mortalitas serta beban biaya yang dibutuhkan. Intervensi koronerperkutan (IKP) dan terapi antiplatelet seperti klopidogrel merupakan tata laksana yangdirekomendasikan oleh organisasi kardiologi internasional. Meskipun demikian, pasienSKA masih dapat mengalami kejadian kardiovaskular mayor (KKM). Kemungkinan,resistensi klopidogrel berperan pada KKM sedangkan resistensi klopidogrel mungkindipengaruhi oleh faktor genetik dan epigenetik. Penelitian ini bertujuan untuk mengetahuihubungan faktor genetik yaitu polimorfisme gen CYP2C19 dan P2Y12, serta epigenetikyaitu metilasi DNA gen CYP2C19 dan P2Y12 serta ekspresi miRNA-26a dengan resistensiklopidogrel dan pengaruhnya terhadap KKM pada pasien SKA pasca IKP.Untuk menganalisis hubungan faktor genetik dan epigenetik dengan resistensi klopidogrel,penelitian dilakukan dengan desain potong lintang, sedangkan untuk analisis hubunganfaktor genetik dan epigenetik dengan KKM dilakukan dengan desain kohort prospektif.Subjek penelitian meliputi 201 pasien SKA pasca IKP dan mendapat terapi klopidogrel diRumah Sakit Jantung dan Pembuluh Darah Harapan Kita dari bulan September 2018sampai dengan Juni 2020. Resistensi klopidogrel ditentukan dengan pemeriksaan lighttransmission aggregometry (LTA) apabila hasilnya lebih besar dari 59% dengan agonisADP 20 M. Deteksi polimorfisme gen CYP2C19 dan P2Y12 serta ekspresi miRNA-26adilakukan dengan metode qRT-PCR, sedangkan metilasi DNA gen CYP2C19 dan P2Y12dikerjakan dengan metode konversi bisulfit. Pasien diobservasi selama satu tahun dan jikaada angina pektoris, infark miokard akut (IMA) rekuren, stroke, atau kematian, dicatatsebagai KKM.Dari 201 subjek, terdapat 45,8% carrier mutant polimorfisme *2 dan *3 gen CYP2C19,36,8% carrier mutant polimorfisme rs3679479 gen P2Y12, 10% hipometilasi DNA genP2Y12, 80,1% hipometilasi DNA gen CYP2C19, dan 66,2% ekspresi miRNA-26a upregulated. Proporsi resisten klopidogrel adalah 49,8% dan proporsi KKM adalah 14,9%(kematian 7,5%). Terdapat hubungan antara merokok (p = 0,001; OR 0,37 [IK 95%; 0,20–0,68]), hipometilasi DNA gen CYP2C19 (p = 0,037; OR 2,13 [IK 95%; 1,04–4,37]), danekspresi miRNA-26a up regulated (p = 0,020; OR 2,03 [IK 95%; 1,12–3,68]) denganresistensi klopidogrel. Terdapat hubungan antara jenis kelamin perempuan (p = 0,040; HR2,73 [IK 95%; 1,05–7,14]), usia ≥ 60 tahun (p = 0,035; HR 2,17 [IK 95%; 1,06–4,48]),eGFR rendah (p = 0,001; HR 3,29 [IK 95%; 1,59–6,84]), dan polimorfisme *2 dan *3 genCYP2C19 (p = 0,047; HR 2,12 [IK 95%; 1,01–4,46]) dengan KKM dalam satu tahun.Hanya faktor epigenetik berupa metilasi DNA gen CYP2C19 dan ekspresi miRNA-26ayang berhubungan dengan resistensi klopidogrel. Walaupun resistensi klopidogrel tidakberhubungan dengan KKM, terdapat hubungan antara faktor genetik polimorfisme *2 dan*3 gen CYP2C19 dengan KKM.
Kata kunci: faktor epigenetik, faktor genetik, kejadian kardiovaskular mayor, resistensiklopidogrel, sindrom koroner akut


Acute coronary syndrome (ACS) is a national health problem due to high morbidity andmortality, and cost burden as well. Percutaneous coronary intervention (PCI) andantiplatelet therapy such as clopidogrel are recommended. However, ACS patients couldstill experience major adverse cardiovascular events (MACE). Clopidogrel resistancepossibly plays a role in MACE whereas it may be affected by genetic and epigenetic factors.Therefore, the objective of this study was to determine the relationship between geneticfactors which are CYP2C19 and P2Y12 polymorphisms, as well as epigenetic factorswhich are DNA methylation of CYP2C19 and P2Y12, and miRNA-26a expression andtheir effects on MACE in post-PCI patients.To analyze the association between genetic and epigenetic factors and clopidogrelresistance, the study design was cross-sectional, while the study design of relationshipbetween genetic and epigenetic factors and MACE was prospective cohort. The subjectswere 201 post-PCI ACS patients who received clopidogrel therapy at Harapan KitaHospital from September 2018 to June 2020. Clopidogrel resistance was determined bylight transmission aggregometry (LTA) if the result was greater than 59% with agonistADP 20 µM. The detection of CYP2C19 and P2Y12 gene polymorphisms and miRNA-26a expression were carried out by qRT-PCR method, while the DNA methylation of theCYP2C19 and P2Y12 genes were carried out by bisulfite conversion method. Patients wereobserved for one year and angina pectoris, recurrent acute myocardial infarction (AMI),stroke, or death, were recorded as MACE.From 201 subjects, 45.8% were CYP2C19*2 and CYP2C19*3 polymorphism mutantcarrier, 36.8% were rs3679479 P2Y12 polymorphism mutant carrier, 10% werehypomethylated of P2Y12, 80.1% were hypomethylated of CYP2C19, and 66.2% were upregulated in miRNA-26a expression. 49.8% of subjects were clopidogrel resistant and14.9% of subjects experienced MACE (death was 7.5%). Smoking (p = 0.001; OR 0.37 [CI95%; 0.20–0.68]), hypomethylated of CYP2C19 (p = 0.037; OR 2.13 [CI 95%; 1.04–4.37]), and up regulated miRNA-26a expression (p = 0.020; OR 2.03 [CI 95%; 1.12–3.68])were associated with clopidogrel resistance. Female gender (p = 0.040; HR 2.73 [CI 95%;1.05–7.14]), age over 60 years old (p = 0.035; HR 2.17 [CI 95%; 1.06–4.48]), low eGFR(p = 0.001; HR 3.29 [CI 95%; 1.59–6.84]), and CYP2C19*2 and CYP2C19*3polymorphisms (p = 0.047; HR 2.12 [CI 95%; 1.01–4.46]) were associated with MACE inone year.Only DNA methylation of CYP2C19 and miRNA-26a expression were associated withclopidogrel resistance. Although clopidogrel resistance was not associated with MACE,there was association between CYP2C19*2 and CYP2C19*3 polymorphisms and MACE.Keywords: acute coronary syndrome, clopidogrel resistance, epigenetic factor, geneticfactor, major adverse cardiovascular eventsAcute coronary syndrome (ACS) is a national health problem due to high morbidity andmortality, and cost burden as well. Percutaneous coronary intervention (PCI) andantiplatelet therapy such as clopidogrel are recommended. However, ACS patients couldstill experience major adverse cardiovascular events (MACE). Clopidogrel resistancepossibly plays a role in MACE whereas it may be affected by genetic and epigenetic factors.Therefore, the objective of this study was to determine the relationship between geneticfactors which are CYP2C19 and P2Y12 polymorphisms, as well as epigenetic factorswhich are DNA methylation of CYP2C19 and P2Y12, and miRNA-26a expression andtheir effects on MACE in post-PCI patients.To analyze the association between genetic and epigenetic factors and clopidogrelresistance, the study design was cross-sectional, while the study design of relationshipbetween genetic and epigenetic factors and MACE was prospective cohort. The subjectswere 201 post-PCI ACS patients who received clopidogrel therapy at Harapan KitaHospital from September 2018 to June 2020. Clopidogrel resistance was determined bylight transmission aggregometry (LTA) if the result was greater than 59% with agonistADP 20 µM. The detection of CYP2C19 and P2Y12 gene polymorphisms and miRNA-26a expression were carried out by qRT-PCR method, while the DNA methylation of theCYP2C19 and P2Y12 genes were carried out by bisulfite conversion method. Patients wereobserved for one year and angina pectoris, recurrent acute myocardial infarction (AMI),stroke, or death, were recorded as MACE.From 201 subjects, 45.8% were CYP2C19*2 and CYP2C19*3 polymorphism mutantcarrier, 36.8% were rs3679479 P2Y12 polymorphism mutant carrier, 10% werehypomethylated of P2Y12, 80.1% were hypomethylated of CYP2C19, and 66.2% were upregulated in miRNA-26a expression. 49.8% of subjects were clopidogrel resistant and14.9% of subjects experienced MACE (death was 7.5%). Smoking (p = 0.001; OR 0.37 [CI95%; 0.20–0.68]), hypomethylated of CYP2C19 (p = 0.037; OR 2.13 [CI 95%; 1.04–4.37]), and up regulated miRNA-26a expression (p = 0.020; OR 2.03 [CI 95%; 1.12–3.68])were associated with clopidogrel resistance. Female gender (p = 0.040; HR 2.73 [CI 95%;1.05–7.14]), age over 60 years old (p = 0.035; HR 2.17 [CI 95%; 1.06–4.48]), low eGFR(p = 0.001; HR 3.29 [CI 95%; 1.59–6.84]), and CYP2C19*2 and CYP2C19*3polymorphisms (p = 0.047; HR 2.12 [CI 95%; 1.01–4.46]) were associated with MACE inone year.Only DNA methylation of CYP2C19 and miRNA-26a expression were associated withclopidogrel resistance. Although clopidogrel resistance was not associated with MACE,there was association between CYP2C19*2 and CYP2C19*3 polymorphisms and MACE.
Keywords: acute coronary syndrome, clopidogrel resistance, epigenetic factor, geneticfactor, major adverse cardiovascular events