When is the Best Time for the Second Antiplatelet Agent in Non-St Elevation Acute Coronary Syndrome?

Abstract

Dual antiplatelet therapy is a well-established treatment in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), with class I of recommendation (level of evidence A) in current national and international guidelines. Nonetheless, these guidelines are not precise or consensual regarding the best time to start the second antiplatelet agent. The evidences are conflicting, and after more than a decade using clopidogrel in this scenario, benefits from the routine pretreatment, i.e. without knowing the coronary anatomy, with dual antiplatelet therapy remain uncertain. The recommendation for the upfront treatment with clopidogrel in NSTE-ACS is based on the reduction of non-fatal events in studies that used the conservative strategy with eventual invasive stratification, after many days of the acute event. This approach is different from the current management of these patients, considering the established benefits from the early invasive strategy, especially in moderate to high-risk patients. The only randomized study to date that specifically tested the pretreatment in NSTE-ACS in the context of early invasive strategy, used prasugrel, and it did not show any benefit in reducing ischemic events with pretreatment. On the contrary, its administration increased the risk of bleeding events. This study has brought the pretreatment again into discussion, and led to changes in recent guidelines of the American and European cardiology societies. In this paper, the authors review the main evidence of the pretreatment with dual antiplatelet therapy in NSTE-ACS.

Efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI): a systematic review and meta-analysis

“…In the TRITON-TIMI (therapeutic outcomes by optimizing platelet inhibition with prasugrel thrombolysis in myocardial infarction) trial, there was a reduction in ischemic endpoints (viz. death from the vascular cause, MI, stroke) in patients treated with ticagrelor [ 22 , 23 ]. There was a higher incidence of bleeding complications in comparison with clopidogrel.…”

The GRACE score is not a good predictor of angiographic complexity in acute coronary syndrome

“…This enables, for instance, a safer determination of the ideal moment to initiate a second antiplatelet agent, reducing the risk of periprocedural bleeding and the need for blood transfusion. 28 The severity of CAD can be classified in different ways. The most commonly used is segregation by LMCA involvement and the number of vessels occluded.…”

O Melhor do Ano 2020 nos Arquivos Brasileiros de Cardiologia e na Revista Portuguesa de Cardiologia

“…Em outro estudo publicado na RPC em 2020, também baseado nos dados do Registro Nacional de SCA da Sociedade Portuguesa de Cardiologia, os autores abordaram um dos grandes temas de discussão científica atual, ou seja o melhor timing para a administração do segundo antiplaquetário (inibidor da P2Y12) em pacientes com SCA com supradesnivelamento do segmento ST: administração pré‐tratamento ou apenas no momento da angioplastia. 17 , 18 Para essa análise foram incluídos 4.123 pacientes com SCA, 66% dos quais foram medicados com o inibidor da P2Y12 antes da angioplastia. 19 Na análise multivariada, observou‐se que os pacientes que receberam o inibidor da P2Y12 antes da angioplastia apresentaram aumento significativo do desfecho hemorrágico combinado (hemorragia maior, transfusão/queda de hemoglobina > 2g/dl), queda de hemoglobina > 2g/dl e reinfarto e nenhum benefício em termos de redução de eventos adversos CV maiores (MACE) ou morte intra‐hospitalar.…”