Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Oral Antiplatelet Therapy in Acute Coronary Syndromes: Recent Developments

Oral Antiplatelet Therapy in Acute Coronary Syndromes: Recent Developments The purpose of this article is to summarize the current knowledge about treatment with oral platelet inhibitors in patients with acute coronary syndrome (ACS). Antiplatelet therapy has been shown to improve the prognosis of patients with ACS with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation ACS (NSTE-ACS). Aspirin should be given with a loading dose of 250–500 mg, followed by 75–100 mg/day. Dual antiplatelet therapy is recommended for all patients with ACS for 12 months regardless of the initial revascularization strategy. Clopidogrel should be administered at first medical contact in STEMI with a loading dose of 600 mg. In patients with ACS and percutaneous coronary intervention (PCI) 2 × 75 mg clopidogrel should be given daily over 7 days, while in all other patients 75 mg per day appears to be sufficient. The two newer adenosine diphosphate-receptor antagonists prasugrel and ticagrelor lead to a more rapid and effective inhibition of platelet aggregation compared with clopidogrel, which was associated with an improved clinical outcome in two large randomized studies. Prasugrel is indicated in patients with ACS undergoing PCI and was most effective in diabetics and in patients with STEMI. In the recent TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes trial in medically treated patients with NSTE-ACS, prasugrel did not significantly reduce ischemic events compared with clopidogrel. Ticagrelor has been studied in the whole spectrum of ACS patients and reduced cardiovascular and total mortality in comparison with clopidogrel. The greatest benefit has been observed in patients with planned conservative treatment and in patients with impaired renal function. Expanding antiplatelet therapy from dual to triple therapy including a platelet thrombin receptor antagonist in the thrombin receptor antagonist for clinical event reduction in acute coronary syndrome trial was not associated with a significant reduction in the primary combined endpoint but an increase in bleeding complications. However, in the Thrombin Receptor Antagonist in Secondary Prevention of atherothrombotic ischemic events study in patients with prior myocardial infarction, vorapaxar on top of standard antiplatelet therapy was effective. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cardiology and Therapy Springer Journals

Oral Antiplatelet Therapy in Acute Coronary Syndromes: Recent Developments

Zeymer, Uwe
Cardiology and Therapy , Volume 2 (1) – Feb 28, 2013
Download PDF
10 pages

Loading next page...
 
/lp/springer-journals/oral-antiplatelet-therapy-in-acute-coronary-syndromes-recent-0AuPqXblnE
Publisher
Springer Journals
Copyright
Copyright © 2013 by The Author(s)
Subject
Medicine & Public Health; Internal Medicine; Cardiology
ISSN
2193-8261
eISSN
2193-6544
DOI
10.1007/s40119-013-0011-6
pmid
25135288
Publisher site
See Article on Publisher Site

Abstract

The purpose of this article is to summarize the current knowledge about treatment with oral platelet inhibitors in patients with acute coronary syndrome (ACS). Antiplatelet therapy has been shown to improve the prognosis of patients with ACS with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation ACS (NSTE-ACS). Aspirin should be given with a loading dose of 250–500 mg, followed by 75–100 mg/day. Dual antiplatelet therapy is recommended for all patients with ACS for 12 months regardless of the initial revascularization strategy. Clopidogrel should be administered at first medical contact in STEMI with a loading dose of 600 mg. In patients with ACS and percutaneous coronary intervention (PCI) 2 × 75 mg clopidogrel should be given daily over 7 days, while in all other patients 75 mg per day appears to be sufficient. The two newer adenosine diphosphate-receptor antagonists prasugrel and ticagrelor lead to a more rapid and effective inhibition of platelet aggregation compared with clopidogrel, which was associated with an improved clinical outcome in two large randomized studies. Prasugrel is indicated in patients with ACS undergoing PCI and was most effective in diabetics and in patients with STEMI. In the recent TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes trial in medically treated patients with NSTE-ACS, prasugrel did not significantly reduce ischemic events compared with clopidogrel. Ticagrelor has been studied in the whole spectrum of ACS patients and reduced cardiovascular and total mortality in comparison with clopidogrel. The greatest benefit has been observed in patients with planned conservative treatment and in patients with impaired renal function. Expanding antiplatelet therapy from dual to triple therapy including a platelet thrombin receptor antagonist in the thrombin receptor antagonist for clinical event reduction in acute coronary syndrome trial was not associated with a significant reduction in the primary combined endpoint but an increase in bleeding complications. However, in the Thrombin Receptor Antagonist in Secondary Prevention of atherothrombotic ischemic events study in patients with prior myocardial infarction, vorapaxar on top of standard antiplatelet therapy was effective.

Journal

Cardiology and Therapy – Springer Journals

Published: Feb 28, 2013

References

  • ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
    Hamm, C; Bassand, J-P; Agewall, S
  • ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update)
    Jneid, H; Anderson, JL
  • Low dose aspirin for the prevention of atherothrombosis
    Patrono, C; Garcia Rodriguez, LA; Landolfi, R
  • Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. The Current-OASIS 7 investigators
    Mehta, S; Bassand, J; Chrolavicius, S
  • Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation
    Yusuf, S; Zhao, F; Mehta, SR
  • A randomized comparison of high clopidogrel loading doses in patients with non-ST segment elevation acute coronary syndromes. The ALBION trial
    Montalescot, G; Sideris, G; Meulemann, C; Bal-dit Sollie, RC
  • Double-dose versus standard-dose clopidogrel and high-dose versus low-dose Aspirin in individuals undergoing percutaneous coronary intervention for acute Coronary syndromes (CURRENT OASIS 7): a randomised factorial trial
    Mehta, S; Tanguay, J; Eikelboom, J
  • Efficacy and safety of a high loading dose of clopidogrel administered prehospitally to improve primary percutaneous coronary intervention in acute myocardial infarction: the randomized CIPAMI trial
    Zeymer, U; Arntz, H-R; Mark, B
  • Effect of upstream clopidogrel treatment in patients with ST-segment elevation Myocardial infarction undergoing primary percutaneous coronary intervention
    Koul, S; Smith, G; Scherstén, F
  • Genetic variants in ABCB1 and CYP2C19 and cardiovascular outcomes after treatment with clopidogrel and prasugrel in the TRITON-TIMI 38 trial: a pharmacogenetic analysis
    Mega, JL; Close, SL; Viviott, SD
  • Prasugrel compared with high-dose clopidogrel in acute coronary syndrome. The randomised, double-blind ACAPULCO study
    Montalescot, G; Sideris, G; Cohen, R
  • Inhibitory effects of ticagrelor compared with clopidogrel on platelet function in patients with acute coronary syndromes
    Storey, R; Angiolillo, D; Patil, S
  • Prasugrel vs. clopidogrel in patients with acute coronary syndromes
    Wiviott, SD; Braunwald, E; McCabe, CH
  • Ticagrelor versus clopidogrel in patients with acute coronary syndromes
    Wallentin, L; Becker, R; Budaj, A
  • Ticagrelor versus clopidogrel in acute coronary syndromes in relation to renal function
    James, S; Budaj, A; Aylward, P
  • Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery
    Held, C; Åsenblad, N; Bassand, J
  • Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial
    Montalescot, G; Wiviott, S; Braunwald, E
  • Greater clinical benefit of more intense oral antiplatelet therapy in patients with diabetes mellitus in the TRITON-TIMI 38 trial
    Wiviott, SD; Braunwald, E; Angiolillo, DJ
  • Prasugrel versus clopidogrel for acute coronary syndromes without revascularization
    Roe, MT; Armstrong, P; Fox, KAA
  • Safety and feasibility of adjunctive antiplatelet therapy with intravenous elinogrel, a direct-acting and reversible P2Y12 ADP-receptor antagonist, before primary percutaneous intervention in patients with ST-elevation myocardial infarction: The Early Rapid ReversAl of Platelet ThromboSis with Intravenous Elinogrel before PCI to Optimize REperfusion in Acute Myocardial Infarction (ERASE MI) pilot trial
    Berger, J; Roe, M; Gibson, C
  • Rationale and design of the randomized, double-blind trial testing INtraveNous and Oral administration of elinogrel, a selective and reversible P2Y12-receptor inhibitor, versus clopidogrel to eVAluate Tolerability and Efficacy in nonurgent Percutaneous Coronary Interventions patients (INNOVATE-PCI)
    Leonardi, S; Rao, SV; Harrington, RA
  • Thrombin-receptor antagonist vorapaxar in acute coronary syndromes
    Tricoci, P; Huang, Z; Held, C
  • Vorapaxar for secondary prevention of thrombotic events for patients with previous myocardial infarction: a prespecified subgroup analysis of the TRA 2°P-TIMI 50 trial
    Scirica, BM; Bonaca, MP; Braunwald, E
  • Vorapaxar for the secondary prevention of ischemic events in patients with previuous myocardial infarction: a prespecified subgroup analysis of the TRA-2P trial
    Scirica, B; Bonaca, MP; Braunwald, E
  • Safety and tolerability of atopaxar in the treatment of patients with acute coronary syndromes
    Donoghue, M; Bhatt, D; Wiviott, S
  • Double-blind, placebo-controlled Phase II studies of the protease-activated receptor 1 antagonist E5555 (atopaxar) in Japanese patients with acute coronary syndrome or high-risk coronary artery disease
    Goto, S; Ogawa, H; Takeuchi, M; Flather, MD; Bhatt, DL
  • Bleeding in acute coronary syndromes and percutaneous coronary interventions: position paper by the Working Group on thrombosis of the European Cardiac Society
    Collet, JP; Huber, K; Andreotti, F
  • Implications of variability in definition and reporting of major bleeding in randomized trials comparing oral P2Y12 inhibitors for acute coronary syndromes
    Quilain, DJ; Eickelboom, J; Goodman, S
  • Bedside monitoring to adjust antiplatelet therapy for coronary stenting
    Collet, JP; Ciusset, T; Range, G