What is new in antiplatelets for secondary prevention of coronary artery disease...? What is new in antiplatelets for secondary prevention of coronary artery disease...?

Dr. Akshay Kashid

Authors

Dr. Akshay Kashid Senior Resident Department of Cardiology, Dr Anil Sharma2 – Prof and Head Department of Cardiology (Bombay hospital, Mumbai)

Abstract

Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y12 receptor inhibitor has shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing Percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy, but with increased risk of major bleeding. The optimal duration of DAPT remains uncertain, and several larger and randomised trials also give conflicting result. Shorter duration DAPT (3–6months) after PCI was non-inferior to 12 months duration with respect to MACE, but reduced major bleeding. Similarly, prolonged DAPT durations (18–48 months) reduced the incidence of MI and stent thrombosis, but caused major bleeding. So, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation. Based on limited evidence, 12 months duration of DAPT is currently recommended.

References

Baigent C, ,et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta. Lancet2009; 373:1849–60.

Montalescot G, Sechtem U, ,et al. ESC guidelines on the management of stable coronary artery disease. Eur Heart J2013; 2013:2949–3003.

RoffiMet al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016;

:267–315.

CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemicevents(CAPRIE). Lancet1996; 348:1329–39.

Bhatt DL, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N EnglJMed 2006; 354:1706–17.

Schömig Aet al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med1996; 334:1084–9.

Leon MB et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. N Engl J Med1998; 339:1665–71.

Urban P, Macaya Cet al. Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: (MATTIS). Circulation1998; 98:2126–32.

Steinhubl SR, Berger PB, Mann JT, et al. Early and sustained dual oral antiplatelet therapy following PCI: a randomized controlled trial. JAMA 2002;288:2411–20

Stefanini GG, TaniwakiM, Windecker S. Coronary stents: novel developments. Heart 2014; 100:1051–61.

GwonHCet al. Six-month versus 12-month dual antiplatelet therapy after DES: the Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting (EXCELLENT) randomized, multicenter study. Circulation2012; 125:505–13.

Kim BK et al. A new strategy for discontinuation of dual antiplatelet therapy: the

RESETT ria l(Real Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation). J Am CollCardiol2012; 60:1340–8.

Fereset al. Three vs. twelve months of dual antiplatelet therapy after zotarolimus- eluting stents. JAMA2013; 310:2510–22.

Colombo Aet al. Second-generation drug- eluting stent implantation followed by 6- Versus 12-month dual antiplatelet therapy. J Am CollCardiol2014; 64:2086–97.

Schulz-Schüpke S, Byrne RA, Ten Berg JM, et al. ISAR-SAFE:

arandomized,double-blind,placebo-controlledtrialof6vs.12 months of clopidogrel therapy after drug-eluting stenting. EurHeartJ2015; 36:1252–63.

Mauri L, Kereiakes DJ, YehRW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med2014; 371:2155–66. 17) Park SJ, Park DW, Kim YH, et al. Duration of dual antiplatelet therapy after implantation of drug-eluting stents. N Engl J Med2010; 362:1374–82.

Lee CW, Ahn JM, Park DW, et al. Optimal duration of dual antiplatelet therapy after drug-eluting stent implantationCirculation2014; 129:304–12.

Mauri Let al. Causes of late mortality with dual antiplatelet therapy after coronary stents. Eur Heart J2016;37:378–85

GLOBAL LEADERS: https://doi.org/10.1016/S0140-6736(18)31858-0

Roxana Mehran et al Ticagrelorwith or without Aspirin in High-Risk Patients after

PCI:N Engl J Med 2019; 381:2032-2042DOI: 10.1056/NEJMoa1908419

Mehta SR, BassandJP, Chrolavicius S, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med2010; 363:930–42.

James SK, Roe MT, CannonCP, et al. Ticagrelor versus clopidogrel in patients with

ACS for non-invasive management: substudy from PLATO trial. BMJ2011; 342:d3527.

Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with ACS; NEJM 2007;357:2001–15

Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrelin patients with acute coronary syndromes. N Engl J Med2009;361:1045–57

Motovska Z, Hlinomaz O, Miklik R, et al. Prasugrel versus ticagrelorin patients with AMI treated with PCI: multicenter randomized PRAGUE-18 study. Circulation2016; 134:1603–12.

Lip GY, Windecker S, Huber K, et al. Management of antithrombotic therapy in AF patients presenting with ACS and/or undergoing PCI, Eur Heart journal 2014;35:3155–79

What is new in antiplatelets for secondary prevention of coronary artery disease...?