The East Asian Paradox: An Updated Position Statement on the Challenges to the Current Antithrombotic Strategy in Patients with Cardiovascular Disease

Abstract

East Asian patients have reduced anti-ischemic benefits and increased bleeding risk during antithrombotic therapies compared with Caucasian patients. As potent P2Y12 receptor inhibitors (e.g., ticagrelor and prasugrel) and direct oral anticoagulants are commonly used in current daily practice, the unique risk–benefit trade-off in East Asians has been a topic of emerging interest. In this article, we propose updated evidence and future directions of antithrombotic treatment in East Asian patients.

Ethnic Difference of Thrombogenicity in Patients with Cardiovascular Disease: a Pandora Box to Explain Prognostic Differences

“…Underlying mechanisms associated with the racial disparity in ASCVD incidence and mortality are complex and multifactorial. 1) 7) The ethnic differences in demographics, comorbidities, and disease patterns can influence clinical outcomes. In addition, the polygenic aspect of inherited thrombogenicity (hypercoagulability), and the complex interaction between genetic and epigenetic factors may in part explain the ethnic differences.…”

“…Figure 2 suggests potential mechanism for racial differences in VTE incidence. 1) 4) 6) Genetic variants with the two known polymorphisms associated with VTE risk (factor V Leiden and prothrombin gene polymorphism) found predominantly in European population are believed to account for up to 60% of VTE. 11) Abnormalities in coagulation factors such as deficiencies in protein C, protein S and antithrombin, and elevated factors VIII and XI are at least partially heritable (heritability between 30% and 60%).…”

“…The comparison of major biologic pathways with biomarkers or surrogates provide important clues to explain the racial difference in ASCVD prognosis ( Table 1 ). 1) 20) However, most CHD biomarker research has been conducted in Caucasians, and little is known regarding the actual generalizability of these biomarkers to other ethnic groups. 7) Previous studies indicated that there are marked differences between the races in traditional CV risk factors and the linkage of risk score with observed clinical events, 21) 22) making it difficult to generalize the clinical data derived from current biomarkers and image criteria to all ethnicities.…”

“…Multiple lines of clinical and epidemiologic evidence have suggested that the prevalence of atherosclerotic cardiovascular disease (ASCVD) and related mortality rates differ between patients of different races ( Figure 1 ). 1) 2) 3) 4) Compared with East Asians, Caucasians have greater morbidity and mortality from coronary artery disease (CAD). 2) 3) Morbidity and mortality related to stroke are higher in East Asians than in Caucasians, which may be partly explained by a higher incidence of hemorrhagic stroke in East Asians and the different dominant type of ischemic stroke (i.e., lacunar stroke in East Asians vs. large thromboembolic stroke in Caucasians).…”

Thrombosis and Haemostasis 2020 Editors' Choice Papers

“…Additional high-quality studies, especially prospective and randomized trials, will be necessary to define the optimal range for Asian AF patients. 22,23 High body weight and obese patients represent another subgroup, for whom the risks associated with anticoagulation treatment remains uncertain. The study by Martin et al was well relayed on social media, as it challenged the International Society of Thrombosis and Haemostasis guidance on routinely checking direct oral anticoagulant (DOAC) concentrations in these patients.…”