Antiplatelet and antithrombotic treatment for secondary prevention in ischaemic heart disease

Abstract

Platelets play a key role in the pathogenesis of acute coronary syndromes and this is why antiplatelet drugs are essential, both in the acute phase and in the long-term follow-up in preventing recurrent myocardial infarction, stroke and cardiovascular death. Aspirin is the most used agent and still remains the first choice drug for lifelong administration in secondary prevention after myocardial infarction. Dual antiplatelet therapy, targeting more than one pathway of platelet activation, has significantly improved the outcome of patients with acute coronary syndromes despite an increased risk of bleeding complications. The aim of this article is to provide an overview of the evidence from randomized clinical trials with a focus on the best association between aspirin and a P2Y 12 inhibitor such as clopidogrel, prasugrel or ticagrelor, on the selection of the appropriate agent based on the revascularization strategy and on the optimal duration of such an intensive treatment. We will also provide the latest evidence regarding new antithrombotic agents, such as vorapaxar or low dose rivaroxaban, that could be associated with dual antiplatelet therapy in high risk patients with the aim of further reducing the rate of major ischaemic complications. Finally we will address the issue of patients presenting with atrial fibrillation and a concomitant acute coronary syndrome who frequently need a percutaneous coronary intervention, with a specific focus on the combination therapy of antiplatelet and anticoagulant agents and on the current recommendations of the guidelines.

Antithrombotic therapy and revascularisation strategies in people with diabetes and coronary artery disease

“…25 Moreover, as the effect of antiplatelet therapy may depend on the levels of hyperglycaemia, differences in glycaemic control across RCTs may influence the efficacy of the antiplatelet intervention. 26 Low-dose aspirin is recommended together with a P2Y 12 receptor blocker (dual antiplatelet therapy; DAPT) in secondary prevention post-ACS and/or post-percutaneous coronary intervention (PCI) 27 also in DM (Table 1). Aspirin permanently inhibits cyclooxygenase-1 dependent TXA 2 biosynthesis from platelets.…”

“…3,42 Conversely, the stroke rate was generally lower with PCI. 42,44 Repeated MR was consistently lower with CABG, especially at low ( 22) or intermediate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33) SYNTAX scores, an indicator of the anatomical complexity of CAD. 42,45 In a metaanalysis including 3052 DM patients, PCI with firstgeneration DES was confirmed to be inferior to CABG on death (14% versus 9.7%; risk ratio (RR) 1.51, 95% CI 1.09-2.10) and MI (10.3% versus 5.9%; RR 1.44, 95% CI 0.79-2.6), and superior on the occurrence of stroke (2.3% versus 3.8%; RR 0.59, 95% CI 0.39-0.90).…”

Phospholipase Cγ2 signalling contributes to the haemostatic effect of Notoginsenoside Ft1

“…The potency, safety and administration doses for these drugs were all verified through clinical trials. However, the drawback of bleeding is still ineluctable …”

“…However, the drawback of bleeding is still ineluctable. [2,9,10] Panax notoginseng (Burk) F.H. Chen is mainly produced from Yunnan province of China, and has been used as a Traditional Chinese Medicine (TCM) for hundreds of years due to its amazing effects on replenishing blood, haemostasis and removing blood stasis.…”

Acetylsalicylic acid on primary prevention of cardiovascular diseases

“…The ASCEND study (A Study of Cardiovascular Events iN Diabetes) showed that aspirin every day reduces the risk of the first cardiovascular event in high-risk diabetes patients but also that the benefit is counterbalanced by the risk of bleeding. 1 The ARRIVE study, published simultaneously in the Lancet, has not been able to document a benefit of the primary preventive intake of aspirin every day in non-diabetic and lowrisk cardiovascular subjects. 2 The results of the ASCEND study have shown that, when looking at the risk-benefit balance, the absolute benefit of the reduction of serious vascular events, obtained with aspirin, is largely counterbalanced by the increased risk of bleeding.…”