Risks and benefits of triple oral anti-thrombotic therapies after acute coronary syndromes and percutaneous coronary intervention.

Abstract

The key pathophysiological process underlying symptomatic coronary artery disease, including acute coronary syndromes (ACS), is usually a rupture or an erosion of an atherosclerotic plaque, followed by platelet activation and subsequent thrombus formation. Early clinical trials showed benefit with long-term aspirin treatment, and later-based on large clinical trials-dual anti-platelet therapy (DAPT), initially with clopidogrel, and more recently with prasugrel or ticagrelor, has become the established treatment in the post-ACS setting and after percutaneous coronary intervention (PCI). Treatment with DAPT is recommended for both ST-elevation myocardial infarction and non-ST-elevation ACS, as well as after PCI with stenting, in American and European clinical guidelines. Notwithstanding the benefits observed with DAPT, including third-generation P2Y12 receptor inhibitors plus aspirin, ACS patients remain at high risk for a recurrent cardiovascular event, suggesting that other treatment strategies, including the addition of a third oral anti-platelet agent or a novel oral anticoagulant (NOAC) to standard DAPT regimens, may provide additional benefit for post-ACS patients and for patients undergoing PCI. Adding a third anti-thrombotic agent to DAPT after an ACS event or a PCI procedure has been shown to have modest benefit in terms of ischemic event reduction, but has consistently been associated with increased bleeding complications. Therefore, the quest to optimize anti-thrombotic therapies post-ACS and post-PCI continues unabated but is tempered by the historical experiences to date that indicate that careful patient and dose selection will be critical features of future randomized trials.

• Authors: Joakim Alfredsson, Matthew T Roe
• Journal: Drug safety (Drug Saf) Vol. 38 Issue 5 Pg. 481-91 (May 2015) ISSN: 1179-1942 [Electronic] New Zealand
• PMID: 25829216 (Publication Type: Journal Article, Review)

Chemical References

• Anticoagulants
• Antithrombins
• Platelet Aggregation Inhibitors

Topics

• Acute Coronary Syndrome (drug therapy, surgery)
• Administration, Oral
• Anticoagulants (administration & dosage, adverse effects, therapeutic use)
• Antithrombins (administration & dosage, adverse effects, therapeutic use)
• Combined Modality Therapy (adverse effects)
• Drug Monitoring
• Drug Therapy, Combination (adverse effects)
• Evidence-Based Medicine
• Humans
• Percutaneous Coronary Intervention (adverse effects)
• Platelet Aggregation Inhibitors (administration & dosage, adverse effects, therapeutic use)
• Risk Assessment