Management of Acute Coronary Syndrome in the Hospital: A Focus on ACCF/AHA Guideline Updates to Oral Antiplatelet Therapy

Abstract

The 3 main clinical manifestations of acute coronary syndrome (ACS) are unstable angina, non-ST-segment myocardial infarction, and ST-segment myocardial infarction. Together they comprise a major cause of emergency care and hospitalization in the United States. Consequently, all hospital-based physicians should be familiar with current recommendations regarding the diagnosis and management of ACS. Effective inhibition of platelet activation and aggregation is central to the treatment of ACS, and dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is recommended in all patients with ACS. Recently, the American Heart Association and American College of Cardiology Foundation published focused updates to their guidelines for the management of ACS patients. These updates included changes in antiplatelet therapy arising from the introduction of prasugrel and ticagrelor as alternatives to clopidogrel for the P2Y12 inhibitor component of dual antiplatelet therapy. Among the P2Y12 inhibitors recommended for each indication, the guidelines do not advocate any one P2Y12 inhibitor over another, but instead recommend that therapy is individualized based on each patient's demographic and clinical characteristics. This article presents a clinical case study to illustrate the hospital management of ST-segment myocardial infarction and unstable angina/non-ST-segment myocardial infarction with particular reference to the latest changes in antiplatelet therapy guidelines. This article outlines key differences in the indications and recommendations for P2Y12 inhibitors and summarizes clinical data from the pivotal studies of prasugrel and ticagrelor.

Short‐term vs long‐term dual antiplatelet therapy after drug‐eluting stent implantation in patients undergoing percutaneous coronary intervention: A systematic review and meta‐analysis

“…East Asian ethnicity has unique characteristics in response to platelet drugs. East Asian individuals may have higher rates of bleeding but have comparable or lower rates of ischemic events than Caucasian patients, which is known as the “East Asian paradox” 37‐40 . Two meta‐analyses 20,45 concentrated on the optimal duration of DAPT in East Asian patients undergoing PCI and they found that short‐term DAPT (≤6 months) might be a better choice for East Asian patients undergoing PCI with DES placement, which is in accordance with our conclusions.…”

“…East Asian individuals may have higher rates of bleeding but have comparable or lower rates of ischemic events than Caucasian patients, which is known as the "East Asian paradox". [37][38][39][40] Two meta-analyses 20,45 concentrated on the optimal duration of DAPT in East Asian patients undergoing PCI and they found that short-term DAPT (≤6 months) might be a better choice for East Asian patients undergoing PCI with DES placement, which is in accordance with our conclusions. We did not perform subgroup analysis according to different populations because of the lack of data in the original trials.…”

“…A standard DAPT regimen for 12 months is recommended in guidelines after ACS. 39 Indeed, very late (≥12 months) stent thrombosis has been documented…”

“…With one less antiplatelet medication, the bleeding events are expected to be lower; therefore, the safety of short‐term DAPT was never in question. A standard DAPT regimen for 12 months is recommended in guidelines after ACS 39 . Indeed, very late (≥12 months) stent thrombosis has been documented with first‐generation DESs 40 .…”

Risk Factors for Gastrointestinal Injuries in Acute Coronary Syndrome Patients with Double Antiplatelet Therapy in One-Year Follow-Up

“…Acute coronary syndrome (ACS) is a clinical syndrome comprised of ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). It is characterized by ruptured coronary plaque, platelet activation and aggregation, ischemic stress, and/or myocardial injury [1] [2]. Several decades of investigation and discovery regarding the pathophysiology of plaque rupture and thrombus formation and the clinical benefits of inhibiting platelet activation and aggregation [3] [4] [5] [6] have led to double antiplatelet therapy (clopidogrel combined with low-dose aspirin, DAPT) as a standard antiplatelet therapy [7] [8].…”