Journal of Clinical Medicine

Research

11 pages, 840 KiB

Open AccessArticle

Use of Clopidogrel, Prasugrel, or Ticagrelor and Patient Outcome after Acute Coronary Syndrome in Austria from 2015 to 2017

by Safoura Sheikh Rezaei, Andreas Gleiss, Berthold Reichardt and Michael Wolzt

J. Clin. Med. 2020, 9(11), 3398; https://doi.org/10.3390/jcm9113398 - 23 Oct 2020

Cited by 3 | Viewed by 2391

Abstract

Background: Dual antiplatelet therapy improves patient outcome after acute coronary syndrome (ACS), but prescription differences of P2Y12 inhibitor treatments exist. The aim of the present investigation was to study the long-term utilization and patient outcomes of clopidogrel, prasugrel, and ticagrelor in patients with [...] Read more.

Background: Dual antiplatelet therapy improves patient outcome after acute coronary syndrome (ACS), but prescription differences of P2Y12 inhibitor treatments exist. The aim of the present investigation was to study the long-term utilization and patient outcomes of clopidogrel, prasugrel, and ticagrelor in patients with ACS from 2015 to 2017 in Austria. Methods: Data from 13 Austrian health insurance funds of patients with a hospital discharge diagnosis of ACS for the years 2015 to 2017 were analyzed. The primary end point was to investigate the recurrence of ACS or death. Results: Of 49,124 P2Y12 inhibitor-naive patients with a hospital discharge diagnosis of ACS, 25,147 subjects filled a P2Y12 inhibitor prescription within 30 days after the index event. Of these patients, 10,626 (42.9%) subjects had a prescription for clopidogrel, 4788 (19.3%) for prasugrel, and 9383 (37.8%) for ticagrelor. Ticagrelor was the most frequently prescribed P2Y12 inhibitor among patients below 70 years old, and clopidogrel in those aged ≥70 years. Occurrence of an endpoint was highest in elderly patients. After adjustment for age, sex, and pre-existing medication as proxy for comorbidity, the hazard ratio for ACS or death for prasugrel vs. clopidogrel of 0.70 (95% CI: 0.61; 0.79) was similar to that of ticagrelor vs. clopidogrel (0.70; 95% CI: 0.64; 0.77). Conclusion: Prescription of ticagrelor or prasugrel after ACS were associated with a lower risk of ACS recurrence or death compared to clopidogrel. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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10 pages, 1201 KiB

Open AccessArticle

Rationale and Design of the Future Optimal Research and Care Evaluation in Patients with Acute Coronary Syndrome (FORCE-ACS) Registry: Towards “Personalized Medicine” in Daily Clinical Practice

by Dean R. P. P. Chan Pin Yin, Gert-Jan A. Vos, Niels M. R. van der Sangen, Ronald Walhout, R. Melvyn Tjon Joe Gin, Deborah M. Nicastia, Jorina Langerveld, Daniël M. F. Claassens, Marieke E. Gimbel, Jaouad Azzahhafi, Willem L. Bor, Tom Oirbans, Johan Dekker, Georgios J. Vlachojannis, Rutger J. van Bommel, Yolande Appelman, José P. S. Henriques, Wouter J. Kikkert and Jurriën M. ten Berg

J. Clin. Med. 2020, 9(10), 3173; https://doi.org/10.3390/jcm9103173 - 30 Sep 2020

Cited by 12 | Viewed by 5475

Abstract

Diagnostic and treatment strategies for acute coronary syndrome have improved dramatically over the past few decades, but mortality and recurrent myocardial infarction rates remain high. An aging population with increasing co-morbidities heralds new clinical challenges. Therefore, in order to evaluate and improve current [...] Read more.

Diagnostic and treatment strategies for acute coronary syndrome have improved dramatically over the past few decades, but mortality and recurrent myocardial infarction rates remain high. An aging population with increasing co-morbidities heralds new clinical challenges. Therefore, in order to evaluate and improve current treatment strategies, detailed information on clinical presentation, treatment and follow-up in real-world patients is needed. The Future Optimal Research and Care Evaluation in patients with Acute Coronary Syndrome (FORCE-ACS) registry (ClinicalTrials.gov Identifier: NCT03823547) is a multi-center, prospective real-world registry of patients admitted with (suspected) acute coronary syndrome. Both non-interventional and interventional cardiac centers in different regions of the Netherlands are currently participating. Patients are treated according to local protocols, enabling the evaluation of different diagnostic and treatment strategies used in daily practice. Data collection is performed using electronic medical records and quality-of-life questionnaires, which are sent 1, 12, 24 and 36 months after initial admission. Major end points are all-cause mortality, myocardial infarction, stent thrombosis, stroke, revascularization and all bleeding requiring medical attention. Invasive therapy, antithrombotic therapy including patient-tailored strategies, such as the use of risk scores, pharmacogenetic guided antiplatelet therapy and patient reported outcome measures are monitored. The FORCE-ACS registry provides insight into numerous aspects of the (quality of) care for acute coronary syndrome patients. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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11 pages, 701 KiB

Open AccessArticle

P2Y12 Inhibitor Monotherapy with Clopidogrel versus Ticagrelor in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

by Po-Wei Chen, Wen-Han Feng, Ming-Yun Ho, Chun-Hung Su, Sheng-Wei Huang, Chung-Wei Cheng, Hung-I Yeh, Ching-Pei Chen, Wei-Chun Huang, Ching-Chang Fang, Hui-Wen Lin, Sheng-Hsiang Lin, I-Chang Hsieh and Yi-Heng Li

J. Clin. Med. 2020, 9(6), 1657; https://doi.org/10.3390/jcm9061657 - 1 Jun 2020

Cited by 9 | Viewed by 4028

Abstract

Background: P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). However, the ideal P2Y12 inhibitor for monotherapy is unclear. Methods and Results: We performed a multicenter, retrospective, observational study to compare the efficacy and safety of monotherapy [...] Read more.

Background: P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). However, the ideal P2Y12 inhibitor for monotherapy is unclear. Methods and Results: We performed a multicenter, retrospective, observational study to compare the efficacy and safety of monotherapy with clopidogrel versus ticagrelor in patients with acute coronary syndrome (ACS) undergoing PCI. From 1 January 2014 to 31 December 2018, 610 patients with ACS who received P2Y12 monotherapy with either clopidogrel (n = 369) or ticagrelor (n = 241) after aspirin was discontinued prematurely were included. Inverse probability of treatment weighting was used to balance covariates between the groups. The primary endpoint was the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. Overall, 84 patients reached the primary endpoint, with 57 (15.5%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. Multivariate adjustment in Cox proportional-hazards models revealed a lower risk of the primary endpoint with ticagrelor than with clopidogrel (adjusted hazard ratio (aHR): 0.67, 95% confidence interval (CI): 0.49–0.93). Ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR: 0.46, 95% CI: 0.28–0.75). No significant difference in all-cause mortality and major bleeding events was observed between the 2 groups. Conclusions: Among patients with ACS undergoing PCI who cannot complete course of dual antiplatelet therapy, a significantly lower risk of cardiovascular events was associated with ticagrelor monotherapy than with clopidogrel monotherapy. The major bleeding risk was similar in both the groups. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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17 pages, 2115 KiB

Open AccessArticle

Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes

by Shashank Murali, Sara Vogrin, Samer Noaman, Diem T. Dinh, Angela L. Brennan, Jeffrey Lefkovits, Christopher M. Reid, Nicholas Cox and William Chan

J. Clin. Med. 2020, 9(5), 1426; https://doi.org/10.3390/jcm9051426 - 11 May 2020

Cited by 13 | Viewed by 3057

Abstract

Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing [...] Read more.

Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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11 pages, 1991 KiB

Open AccessArticle

High Platelet Reactivity after Transition from Cangrelor to Ticagrelor in Hypothermic Cardiac Arrest Survivors with ST-Segment Elevation Myocardial Infarction

by Nina Buchtele, Harald Herkner, Christian Schörgenhofer, Anne Merrelaar, Roberta Laggner, Georg Gelbenegger, Alexander O. Spiel, Hans Domanovits, Irene Lang, Bernd Jilma and Michael Schwameis

J. Clin. Med. 2020, 9(2), 583; https://doi.org/10.3390/jcm9020583 - 21 Feb 2020

Cited by 8 | Viewed by 3302

Abstract

Transition from cangrelor to oral P2Y12 inhibitors after PCI carries the risk of platelet function recovery and acute stent thrombosis. Whether the recommended transition regimen is appropriate for hypothermic cardiac arrest survivors is unknown. We assessed the rate of high platelet reactivity (HPR) [...] Read more.

Transition from cangrelor to oral P2Y12 inhibitors after PCI carries the risk of platelet function recovery and acute stent thrombosis. Whether the recommended transition regimen is appropriate for hypothermic cardiac arrest survivors is unknown. We assessed the rate of high platelet reactivity (HPR) after transition from cangrelor to ticagrelor in hypothermic cardiac arrest survivors. Adult survivors of out-of-hospital cardiac arrest with ST-segment elevation myocardial infarction (STEMI), who were treated for hypothermia (33 °C ± 1) and received intravenous cangrelor during PCI and subsequent oral loading with 180mg ticagrelor were enrolled in this prospective observational cohort study. Platelet function was assessed using whole blood aggregometry. HPR was defined as AUC > 46U. The primary endpoint was the rate of HPR (%) at predefined time points during the first 24 h after cangrelor cessation. Poisson regression was used to estimate the relationship between the overlap time of cangrelor and ticagrelor co-administration and the number of subsequent HPR episodes, expressed as incidence rate ratio (IRR) with 95% confidence interval (95%CI). Between December 2017 and October 2019 16 patients (81% male, 58 years) were enrolled. On average, ticagrelor was administered 39 min (IQR 5–50) before the end of cangrelor infusion. The rate of HPR was highest 90 min after cangrelor cessation and was present in 44% (7/16) of patients. The number of HPR episodes increased significantly with decreasing overlap time of cangrelor and ticagrelor co-administration (IRR 1.03, 95%CI 1.01–1.05; p = 0.005). In this selected cohort of hypothermic cardiac arrest survivors who received cangrelor during PCI, ticagrelor loading within the recommended time frame before cangrelor cessation resulted in a substantial amount of patients with HPR. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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Review

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16 pages, 1614 KiB

Open AccessReview

Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines

by Paul Guedeney and Jean-Philippe Collet

J. Clin. Med. 2020, 9(11), 3474; https://doi.org/10.3390/jcm9113474 - 28 Oct 2020

Cited by 22 | Viewed by 20891

Abstract

The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients [...] Read more.

The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients presenting without persistent ST-segment elevation myocardial infarction have incorporated the most recent breakthroughs and updates from large randomized controlled trials (RCT) on the diagnosis and management of this disease. The purpose of the present review is to describe the main novelties and the rationale behind these recommendations. Hence, we describe the accumulating evidence against P2Y₁₂ receptors inhibitors pretreatment prior to coronary angiography, the preference for prasugrel as leading P2Y₁₂ inhibitors in the setting of ACS, and the numerous available antithrombotic regimens based on various durations of dual or triple antithrombotic therapy, according to the patient ischemic and bleeding risk profiles. We also detail the recently implemented 0 h/1 h and 0 h/2 h rule in, rule out algorithms and the growing role of computed coronary tomography angiography to rule out ACS in patients at low-to-moderate risk. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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16 pages, 473 KiB

Open AccessReview

Risk Assessment Using Risk Scores in Patients with Acute Coronary Syndrome

by Dean Chan Pin Yin, Jaouad Azzahhafi and Stefan James

J. Clin. Med. 2020, 9(9), 3039; https://doi.org/10.3390/jcm9093039 - 21 Sep 2020

Cited by 25 | Viewed by 6904

Abstract

Risk scores are widely used in patients with acute coronary syndrome (ACS) prior to treatment decision-making at different points in time. At initial hospital presentation, risk scores are used to assess the risk for developing major adverse cardiac events (MACE) and can guide [...] Read more.

Risk scores are widely used in patients with acute coronary syndrome (ACS) prior to treatment decision-making at different points in time. At initial hospital presentation, risk scores are used to assess the risk for developing major adverse cardiac events (MACE) and can guide clinicians in either discharging the patients at low risk or swiftly admitting and treating the patients at high risk for MACE. During hospital admission, risk assessment is performed to estimate mortality, residual ischemic and bleeding risk to guide further in-hospital management (e.g., timing of coronary angiography) and post-discharge management (e.g., duration of dual antiplatelet therapy). In the months and years following ACS, long term risk can also be assessed to evaluate current treatment strategies (e.g., intensify or reduce pharmaceutical treatment options). As multiple risk scores have been developed over the last decades, this review summarizes the most relevant risk scores used in ACS patients. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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10 pages, 1069 KiB

Open AccessReview

De-Escalation of Antiplatelet Treatment in Patients with Myocardial Infarction Who Underwent Percutaneous Coronary Intervention: A Review of the Current Literature

by Daniel MF Claassens and Dirk Sibbing

J. Clin. Med. 2020, 9(9), 2983; https://doi.org/10.3390/jcm9092983 - 15 Sep 2020

Cited by 13 | Viewed by 6923

Abstract

In acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), treatment with the P2Y₁₂ inhibitors ticagrelor or prasugrel is recommended over clopidogrel due to a better efficacy, albeit having more bleeding complication. These higher bleeding rates have provoked trials investigating de-escalation [...] Read more.

In acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), treatment with the P2Y₁₂ inhibitors ticagrelor or prasugrel is recommended over clopidogrel due to a better efficacy, albeit having more bleeding complication. These higher bleeding rates have provoked trials investigating de-escalation from ticagrelor or prasugrel to clopidogrel in the hope of reducing bleeding without increasing thrombotic event rates. In this review, we sought to present an overview of the major trials investigating several different options for de-escalation; unguided, platelet function testing- and genotype-guided. Based on these results, and on other established literature sources, such as guidelines and expert consensus papers, we provide an overview to help decide when and how to de-escalate antiplatelet therapy in ACS patients undergoing PCI. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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10 pages, 214 KiB

Open AccessReview

Antithrombotic PreTreatment and Invasive Strategies in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome

by Cyril Camaro and Peter Damman

J. Clin. Med. 2020, 9(8), 2578; https://doi.org/10.3390/jcm9082578 - 9 Aug 2020

Cited by 3 | Viewed by 2589

Abstract

In the current era, the antithrombotic treatment of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) includes standard aspirin, and one of the potent P2Y₁₂ inhibitors ticagrelor or prasugrel. The optimal timing of ticagrelor has not been adequately studied, while prasugrel [...] Read more.

In the current era, the antithrombotic treatment of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) includes standard aspirin, and one of the potent P2Y₁₂ inhibitors ticagrelor or prasugrel. The optimal timing of ticagrelor has not been adequately studied, while prasugrel is only recommended after coronary angiography prior to PCI. The invasive strategy, including indication and timing of angiography, depends on risk stratification and a mortality benefit has been shown in selected high-risk NSTE-ACS undergoing early (<24 h) intervention. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

20 pages, 701 KiB

Open AccessReview

Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

by Gregorio Tersalvi, Luigi Biasco, Giacomo Maria Cioffi and Giovanni Pedrazzini

J. Clin. Med. 2020, 9(7), 2064; https://doi.org/10.3390/jcm9072064 - 1 Jul 2020

Cited by 24 | Viewed by 5971

Abstract

Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead [...] Read more.

Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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18 pages, 1470 KiB

Open AccessReview

New Antithrombotic Drugs in Acute Coronary Syndrome

by Bastiaan Zwart, William A. E. Parker and Robert F. Storey

J. Clin. Med. 2020, 9(7), 2059; https://doi.org/10.3390/jcm9072059 - 30 Jun 2020

Cited by 11 | Viewed by 7449

Abstract

In recent years, much progress has been made in the field of antithrombotic drugs in acute coronary syndrome (ACS) treatment, as reflected by the introduction of the more potent P2Y12-inhibitors prasugrel and ticagrelor, and novel forms of concomitant anticoagulation, such as fondaparinux and [...] Read more.

In recent years, much progress has been made in the field of antithrombotic drugs in acute coronary syndrome (ACS) treatment, as reflected by the introduction of the more potent P2Y12-inhibitors prasugrel and ticagrelor, and novel forms of concomitant anticoagulation, such as fondaparinux and bivalirudin. However, despite substantial improvements in contemporary ACS treatment, there remains residual ischemic risk in this group and hence the need for even more effective antithrombotic drugs, while balancing antithrombotic efficacy against bleeding risk. This review discusses recently introduced and currently developed antiplatelet and anticoagulant drugs in ACS treatment. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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14 pages, 230 KiB

Open AccessReview

Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome

by Wilbert Bor and Diana A. Gorog

J. Clin. Med. 2020, 9(7), 2020; https://doi.org/10.3390/jcm9072020 - 27 Jun 2020

Cited by 5 | Viewed by 3950

Abstract

Acute coronary syndrome and atrial fibrillation are both common and can occur in the same patient. Combination therapy with dual antiplatelet therapy and oral anticoagulation increases risk of bleeding. Where the two conditions coexist, careful consideration is needed to determine the optimal antithrombotic [...] Read more.

Acute coronary syndrome and atrial fibrillation are both common and can occur in the same patient. Combination therapy with dual antiplatelet therapy and oral anticoagulation increases risk of bleeding. Where the two conditions coexist, careful consideration is needed to determine the optimal antithrombotic treatment to reduce the risks of future ischaemic events associated with both conditions. Choices can be made in intraprocedural anticoagulation, type and dosing of oral anticoagulant, duration of combination therapy, and selection of P2Y₁₂ inhibitor including genetic testing. This review article provides an overview of the available evidence to support clinicians in finding the delicate balance between antithrombotic efficacy and bleeding risk in patients with acute coronary syndrome and atrial fibrillation. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

19 pages, 302 KiB

Open AccessReview

Antithrombotic Strategy for Patients with Acute Coronary Syndrome: A Perspective from East Asia

by Yohei Numasawa, Mitsuaki Sawano, Ryoma Fukuoka, Kentaro Ejiri, Toshiki Kuno, Satoshi Shoji and Shun Kohsaka

J. Clin. Med. 2020, 9(6), 1963; https://doi.org/10.3390/jcm9061963 - 23 Jun 2020

Cited by 22 | Viewed by 3960

Abstract

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative [...] Read more.

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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11 pages, 2760 KiB

Open AccessViewpoint

Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome—Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy?

by Ugo Limbruno, Francesco De Sensi, Alberto Cresti, Andrea Picchi, Fabio Lena and Raffaele De Caterina

J. Clin. Med. 2020, 9(8), 2673; https://doi.org/10.3390/jcm9082673 - 18 Aug 2020

Cited by 9 | Viewed by 3812

Abstract

The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk—cardioembolic, coronary, and hemorrhagic—has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic [...] Read more.

The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk—cardioembolic, coronary, and hemorrhagic—has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y₁₂ inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y₁₂ inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF–ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA₂DS₂VASc score 2–4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial. Full article

(This article belongs to the Special Issue Antithrombotic Treatment of Acute Coronary Syndrome)

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