Antithrombotic / Antiplatelet Therapy in Patients with Stable Coronary Artery Disease and After Acute Coronary Syndrome

Abstract

The major physiopathological mechanism underlying Acute Coronary Syndromes (ACS) is atherosclerotic plaque rupture with resultant coronary thrombosis, posing a big burden in health care systems. Dual anti-platelet therapy (DAPT) can improve CV outcome with a prolonged regimen, albeit at the cost of increased bleeding rates. We performed a narrative literature review on the topic, in which we explored databases through April 15th, 2020, with no restrictions on language. Keywords related to antiplatelet therapy, P2Y12 inhibitor, aspirin and DAPT were utilized. Randomized clinical trials, large prospective studies, systematic reviews and meta-analysis were included. We hand-searched the reference lists of included articles and relevant reviews. The review revealed that when choosing antiplatelet agents, the decision should be driven by pharmacodynamic properties as well as demonstrated efficacy and safety. Additionally, it was noted that in patients undergoing percutaneous coronary intervention, prasugrel and ticagrelor are preferred. In patients with a high risk of bleeds or receiving thrombolysis, or when cost or specific patient issues exist, clopidogrel is considered though it is a second-line therapy. Due to an elevated risk of bleeds, triple therapy should be avoided, as evidence shows effectiveness and safety with regimens without ASA. Furthermore, multiple studies have also shown that regimens shorter than 12 months of DAPT could be adequate for many patients, and newer guidelines are likely to reflect it. There are specific recommendations for switching among antiplatelets, mostly based on registries and pharmacodynamic studies.

Keywords: Acute Coronary Syndromes (ACS).; Antiplatelet therapy; Dual Anti-Platelet Therapy (DAPT); P2Y12 inhibitor; aspirin; dual antiplatelet therapy.