P₂Y₁₂inhibitors in neuroendovascular surgery: An opportunity for precision medicine

Abstract

Introduction Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors. Methods Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices. Results Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy. Conclusions The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.

Combined Chiari Malformation Type I and Syringohydromyelia in a Patient With Intractable Headache

“…Dual antiplatelet therapy, comprising aspirin and clopidogrel, has been used as the primary strategy to reduce device-related thromboembolic complications. Based on the latest evidence, a combination of patient pharmacogenetics, drug response monitoring, and a patient-based approach to drug selection is both a predictive and cost-effective mechanism for achieving an individual’s target platelet inhibition levels [ 9 ]. Notably, since the start of venous sinus stenting, multiple changes have persisted in the anticoagulation protocol throughout various studies.…”

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms

“…However, a fixed-dose combination was frequently used without consideration of individual patient variability [ 35 ]. Emerging evidence has highlighted the importance of tailoring DAPT regimens based on patient characteristics, such as genetic polymorphisms, that greatly affect clopidogrel metabolism and response [ 36 ]. A variety of assessments of antiplatelet responsiveness are available, including aggregometry and platelet reactivity assays, which have enabled clinicians to optimize the antiplatelet effect [ 37 ].…”