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Issue 20, 2010
HOT TOPICS IN CARDIOLOGY
Oral antiplatelet agents: new insights in managing patients with acute coronary syndromes
| Publ. date: | 2010 |
| ISBN: | 978-88-6450-042-3 |
| ISSN: | 1973-9621 |
| E-ISSN: | 2036-0924 |
| DOI: | 10.4147/HTC-102000 |
Abstract
Atherosclerotic vascular diseases are a leading cause of morbidity and mortality worldwide. While the acute complications of these conditions may manifest clinically in different ways, including myocardial infarction, stroke, and limb ischemia, they share common pathobiological pathways. Platelet activation and aggregation is recognized as a critical component in the development of these acute atherothrombotic events. Therapies aimed at interrupting this process and preventing acute events have become essential for the care of patients with vascular diseases and remain an area of active development.
Aspirin has become the cornerstone of antiplatelet therapy in patients at risk of atherothrombotic events. At the same time, the addition of P2Y12 inhibitors, such as clopidogrel, has become essential in further reducing the rate of ischemic events in appropriate populations. More potent thienopyridines of the newer generation such as prasugrel offer even further reductions in this risk. While these therapies are increasingly effective at preventing atherothrombotic events, they are also associated with bleeding and require careful patient selection. Currently, novel therapies including the non-thienopyridine P2Y12 inhibitor ticagrelor and the thrombin receptor antagonist SCH 530348 hold the promise of further risk-reduction of ischemic events while maintaining a favorable safety profile.
The growing number of antiplatelet therapies that are available or under development presents a challenge to providers in selecting the best combination of therapies for individual patients and requires careful review of their mechanisms, indications, and risk-benefit profiles.
Table of contents
Foreword
In the past decade, no area of cardiology has been "hotter" than antiplatelet therapy. There has been a revolution in treatment, and it is ongoing.
It began with the addition of ticlopidine to aspirin for prevention of stent thrombosis, as compared to the then standard therapy of aspirin, heparin, sometimes dextran or warfarin. The benefit of dual antiplatelet therapy was huge — a nearly 75% reduction in clinical events. Then, clopidogrel was developed to avoid the hematologic side effects (neutropenia, thrombocytopenia, and thrombotic thrombocytopenic purpura) of ticlopidine. It had no such side effect, and was then used in stenting and in post-stroke prevention. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial found that clopidogrel plus aspirin was more beneficial than aspirin alone in patients with unstable angina or non-ST elevation myocardial infarction (non-STEMI). Benefit was also seen in STEMI, and use expanded greatly. Now there are two new agents that are also P2Y12 inhibitors, but more potent: prasugrel, a third generation thienopyridine, and ticagrelor, the first direct P2Y12 inhibitor that is a reversible oral agent. Both agents produce approximately double the antiplatelet effect of clopidogrel, and each reduced recurrent cardiovascular events over a 12- to 15-month period post-percutaneous coronary intervention and/or acute coronary syndrome. Other agents are being evaluated as well.
Bonaca and Giugliano provide a complete and up-to-the-minute summary of this rapidly evolving field. It is an excellent "state-of-the-art" of oral antiplatelet therapy that I can enthusiastically recommend to everyone.
ARTICLES
Oral antiplatelet agents: new insights in managing patients with acute coronary syndromes
Marc P. Bonaca, Robert P. Giugliano
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Editors-in-chief
Christopher P. Cannon - MD
Sergio Dalla Volta - MD, PhD
While cardiology over the last 15 years has progressed to a great extent in various aspects, it has not progressed in a harmonious manner. Advances in biophysics, molecular biology, genetics, and, les...
Past editor-in-chief
Philip A. Poole-Wilson - MD, FRCP, FACC, FESC, FMedSci
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