Early and Sustained Dual Oral Antiplatelet Therapy Following Percutaneous Coronary Intervention

Abstract

A SPIRIN IS A CORNERSTONE OF therapy for patients undergoing coronary intervention. Its use is considered a standard of care before the procedure and lifelong following revascularization. Adding to aspirin a short course (2-4 weeks) of an adenosine diphosphate (ADP) P2Y 12 receptor antagonist (ticlopidine or clopidogrel) leads to even greater protection from thrombotic complications following a percutaneous coronary intervention (PCI) with a stent. 1-4 However, the optimal timing for the initiation of clopidogrel and aspirin, as well as their duration of treatment following a PCI procedure, remains unknown.The results of multiple observational and nonrandomized studies suggest that treating patients with an ADP receptor antagonist prior to a planned PCI may provide additional, incremental benefit beyond that provided by aspirin, and even beyond that of glycoprotein (Gp) IIb/IIIa antagonists. [5][6][7] Despite the consistency of this observation, patient or procedural characteristics may have biased the results in

Precatheterization Use of P2Y 12 Inhibitors in Non‐ST‐Elevation Myocardial Infarction Patients Undergoing Early Cardiac Catheterization and In‐Hospital Coronary Artery Bypass Grafting: Insights From the National Cardiovascular Data Registry ®

“…In that study, the median time from presentation to catheterization was 10 days, considerably longer than current practice. This concept was later challenged when the CREDO (Clopidogrel for the Reduction of Events During Observation) trial showed no benefit from pretreatment with clopidogrel given 3 hours before PCI but suggested potential reduction of events in patients with longer duration from clopidogrel administration to catheterization 10. The ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non‐ST Elevation Myocardial Infarction) trial showed that precatheterization use of prasugrel did not improve cardiovascular outcomes and was associated with an increase in TIMI (Thrombosis in Myocardial Infarction) major bleeding 6.…”

Variation in Practice Regarding Pretreatment With Dual Antiplatelet Therapy for Patients With Non–ST Elevation Myocardial Infarction

“…Another randomized trial (the Comparison of Prasugrel at the Time of PCI or Pretreatment at the Time of Diagnosis in Patients with Non‐ST Elevation Myocardial Infarction [ACCOAST]) enrolled 4033 NSTEMI patients and found that pretreatment with prasugrel (a more potent antiplatelet agent than clopidogrel) did not decrease adverse cardiac outcomes but rather was associated with increased bleeding 18. Therefore, if patient‐centered reasons (like risk of bleeding) are the cause of the low DAPT pretreatment, then deviating from guidelines may not necessarily provide poor care, especially in light of new emerging evidence 26. In contrast, if site‐level variability accounts for the use of DAPT before coronary angiography independent of patient‐level factors, then it would underscore the importance of quality improvement efforts to improve guideline concordance and improve the consistency of care 27.…”

Platelet Function Measured Using a Whole Blood Aggregometer Can Predict Bleeding Events

“…In receiver operating characteristic curve analysis to distinguish patients taking dual antiplatelet agents (aspirin and ticlopidine) from those not taking antiplatelet drugs, the appropriate cut-off value for the aggregation rate induced by 8 M ADP was 47.3% (85% sensitivity and 81% specificity), which, interestingly, is the same as the mean value for the aggregation rate. Taking these results together, although the positive predictive value of platelet function for the incidence of ischemia is not high, dual antiplatelet therapy may reduce the risk of ischemic events 26,27), provided these dual antiplatelet agents act effectively.…”