Personalised antiplatelet therapies for coronary artery disease: what the future holds

Abstract

Coronary artery disease (CAD) is one of the leading causes of death globally, and antiplatelet therapy is crucial for both its prevention and treatment. Antiplatelet drugs such as aspirin and P2Y12 inhibitors are commonly used to reduce the risk of thrombotic events, including myocardial infarction, stroke, and stent thrombosis. However, the benefits associated with the use of antiplatelet drugs also come with a risk of bleeding complications. The ever-growing understanding of the poor prognostic implications associated with bleeding has set the foundations for defining strategies that can mitigate such safety concern without any trade-off in antithrombotic protection. To this extent, personalised antiplatelet therapy has emerged as a paradigm that optimizes the balance between safety and efficacy by customizing treatment to the individual patient's needs and risk profile. Accurate risk stratification for both bleeding and thrombosis can aid in selecting the optimal antiplatelet therapy and prevent serious and life-threatening outcomes. Risk stratification has traditionally included clinical and demographic characteristics and has expanded to incorporate angiographic features and laboratory findings. The availability of bedside platelet function testing as well as rapid genotyping assays has also allowed for a more individualized selection of antiplatelet therapy. This review provides a comprehensive overview of the current state of the art and future trends in personalised antiplatelet therapy for patients with CAD, with emphasis on those presenting with an acute coronary syndrome and undergoing percutaneous coronary revascularization. The aim is to provide clinicians with a comprehensive understanding of personalised antiplatelet therapy and facilitate informed clinical decision-making.

Strategies for Tailored Antiplatelet Therapy after Percutaneous Coronary Intervention: Unraveling Complexities, Embracing Nuances

“…associated with a higher risk of bleeding 2,8 . Current guidelines for PCI in Europe recommend only guided (or unguided) de-escalation as a class IIb, while there is no corresponding recommendation in guidelines from the United States 9,10 .…”

“…Studies exploring these approaches diverge in their methodologies: the first type involves randomizing HTPR or non-HTPR patients into groups receiving investigational therapies or controls, while the second type randomizes an entire cohort into groups receiving antiplatelet therapy based on a guided or unguided strategy. 2 The effect of these study designs on the actual number of PCI patients who finally receive clopidogrel or a more potent antiplatelet regimen is noteworthy and may impact the overall incidence of ischemic and hemorrhagic complications (►Fig. 1).…”

“…This is likely because most of the trials of genetic or PFT guidance were aimed at identifying candidates to escalation rather than de-escalation, while trials in HTPR patients tested more potent regiments than clopidogrel, which are knowingly associated with a higher risk of bleeding. 2,8 Current guidelines for PCI in Europe recommend only guided (or unguided) de-escalation as a class IIb, while there is no corresponding recommendation in guidelines from the United States. 9,10 Also notably, MACE were reduced in trials of genotype guidance but not in those of PFT guidance.…”

Unraveling the Maze of De-Escalation Strategies in Acute Coronary Syndromes

“…The answer lies in their individual risk profiles, as the external validity of these strategies is contingent on a careful assessment of each patient's unique risk factors and clinical presentation. 1 As we continue to refine our understanding of ACS and its management, the focus must remain on personalized medicine.…”

“…However, it is increasingly acknowledged that each patient's risk profile for bleeding or recurrent ACS varies significantly. 1 Consequently, many alternative strategies have been developed to maximize the net benefit of antiplatelet therapy in this context. The Academic Research Consortium categorizes these strategies into de-escalation and escalation approaches, which involve modulating (ie, decreasing or increasing) platelet inhibition based on the balance between the risk of bleeding and recurrent thrombosis.…”