Triple Antithrombotic Therapy Following Anterior ST-Segment Elevation Myocardial Infarction

Abstract

Fernandez-Portales J. Limitation to the utilization of the new antiplatelet agents in acute coronary syndromes related with patient's characteristics. Rev Esp Cardiol 2015;68:448-50. 5. Wittfeldt A, Emanuelsson H, Brandrup-Wognsen G, et al. Ticagrelor enhances adenosine-induced coronary vasodilatory responses in humans. J Am Coll Cardiol 2013;61:723-7. REPLY: Lights and Shadows of Antiplatelet Therapy in Primary Percutaneous Coronary Intervention We thank Lozano et al. for their thoughtful comments on our ETAMI (Early Thienopyridine Treatment to Improve Primary PCI in Patients With Acute Myocardial Infarction) trial (1) and fully agree with their statement that in antithrombotic therapy, there should always be a balance between efficacy and safety. Our study has investigated the very acute phase of primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) in which a faster onset of action of a platelet inhibition effect is desirable to reduce ischemic complications of the procedure. In the recently published ATLANTIC (A 30 Day Study to Evaluate Efficacy and Safety of Pre-hospital vs. In-hospital Initiation of Ticagrelor Therapy in STEMI Patients Planned for Percutaneous Coronary Intervention) trial, a very early initiation of ticagrelor in the pre-hospital phase leading to clinical relevant difference in platelet inhibition 1 h after PCI was associated with a reduction in stent thrombosis compared with the same loading dose started on average 31 min later in the hospital (2). In addition, there are several reports linking inadequate platelet inhibition at the time of PCI to ischemic complications, underscoring the importance of an effective platelet periprocedural inhibition during primary PCI (3). In the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel) trial, patients with STEMI have especially benefited from prasugrel compared with clopidogrel without an increase in bleeding complications (4). These results were confirmed by recent reports from real-life experience of registries. Bleeding complications in TRITON accumulated over time but were not statistically different between clopidogrel and prasugrel in the primary PCI group at 30 days as well as at 15 months (4). The net clinical benefit was clearly in favor of prasugrel. The statement about a differential effect of prasugrel between secondary and primary PCI in STEMI is not correct, and this reference indicated no statistical heterogeneity between the 2 groups (4).This has been now well evaluated, and there is no significant interaction for the primary and secondary endpoints and a consistent effect of prasugrel across all types of PCI performed in STEMI patients (5). The numerical differences are related to the difficulties in measuring periprocedural MI in primary PCI versus secondary PCI and not related to the efficacy of prasugrel (5). The statement about contraindications against prasugrel majorly relates to patients with prior stroke, which is pr...

Comparison of Systematic Ticagrelor-Based Dual Antiplatelet Therapy to Selective Triple Antithrombotic Therapy for Left Ventricle Dysfunction Following Anterior STEMI

“…Despite early reports of the benefits of adding anticoagulation to standard therapy for patients with anterior MI 15 – 17 , no study that has included PCI patients has demonstrated an advantage of TATT 8 , 18 – 22 . Moreover, despite a recent report that the incidence of LVT following pPCI is not negligible 23 , Le May et al .’s propensity-matched retrospective single-center analysis suggested a higher incidence of NACE with TATT compared with clopidogrel-based DAPT 8 , 24 . Recently, in a mixed pPCI and pharmacoinvasive population, Shavadia et al .…”