Antiplatelet and Antithrombin Strategies in Acute Coronary Syndrome: State-Of-The-Art Review

Abstract

Antiplatelet and antithrombotic agents significantly alter the clinical course of patients with acute coronary syndrome (ACS) and hence form the bedrock of the management pathway of this closely related continuum of coronary pathologies. The contemporary therapeutic armamentarium for the treatment of ACS now reflects the many technical and pharmacological advances that took place over the last two decades. In the original 1996 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of acute myocardial infarction, only one antiplatelet agent (Aspirin) and one anticoagulant (unfractionated heparin) were recommended as class I therapies. Since then many newer agents have been developed and approved for routine clinical use in ACS patients. Recent research has focussed on improving efficacy on one hand and reducing bleeding complications on the other. This review focuses on the mechanism, efficacy, safety profile and clinical trial evidence of P2 Y12 receptor antagonist antiplatelet agents, glycoprotein IIb/IIIa receptor inhibitors (GPI), protease-activated receptor-1 (PAR-1) inhibitors, thrombin inhibitor bivalirudin and Factor Xa inhibitors fondaparinaux and rivaroxaban.

Abciximab‐induced alveolar hemorrhage treated with rescue extracorporeal membranous oxygenation

“…The antiplatelet properties of GP IIb/IIIa inhibitors in combination with the antithrombotic properties of unfracitonated heparin have long been the cornerstone of adjunctive pharmacotherapy in percutaneous coronary intervention (PCI) for acute coronary syndromes, and is supported as a class IIa recommendation by the most recent American Heart Association and American College of Cardiology guidelines for the treatment of ST elevation myocardial infarction . To date, this is the first report of diffuse alveolar hemorrhage in the setting of GP IIb/IIIa use that was treated with veno‐arterial ECMO.…”

Antithrombotic, anticoagulant and antiplatelet activity of betulinic acid and 3β-acetoxybetulinic acid from <i>Melaleuca bracteata</i> ‘Revolution Gold’ (Myrtaceae) Muell leaf

“…Despite the combined drugs-therapy approach, cardiovascular mortality is still on the increase [4]. This faults the potency of the therapy to tackle the links among thrombin, coagulation cascade and platelets functions [12].…”

“…Current drugs such as: aspirin, prasugrel, ticagrelor, clopidogrel, apixban, and warfarin are beneficial, however with undesirable side effects which include: prolonged bleeding time, purpura, thrombocytopenia and gastrointestinal tracts ulcer [4]. In consideration of efficacy to safety ratio in drug design and selection, there is need to search for effective cardiovascular agents with minimal or no side effects especially in prevention of unacceptable bleeding rate [1].…”

Effect of Ticagrelor versus Clopidogrel on Oxidative Stress Bio-markers in Patients with Chronic Stable Angina after Percutaneous Coronary Intervention

“…6 Compared to Clopidogrel and Prasugrel, Ticagrelor inhibit ADP induced platelet aggregation more rapidly and more consistently to a greater extent both in the healthy subjects and in patients with coronary artery disease including those undergoing PCI and reduce the risk of death either resulting from vascular cause, myocardial infarction (MI) or stroke. 7,8 For this reversible binding of Ticagrelor to ADP-receptors, the post percutaneous bleeding tendency in CSA patients would expectedly be lower than that in patients receiving Clopidogrel. 9 In patients of ACS following PCI, the chance of thrombotic phenomenon is increased because of oxidative injury.…”