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Antiplatelet therapy in acute coronary syndromes
Erik L Grove1, Morten Würtz1,2, Mark R Thomas3
1a 1 Aarhus University Hospital, Department of Cardiology , Aarhus, Denmark +45 78 45 20 30 ; +45 78 45 22 60 ; steendk@dadlnet.dk.
Insights
Newer antiplatelet drugs improve outcomes for acute coronary syndromes (ACS) but carry bleeding risks. Research continues for better strategies, as some patients still experience thrombotic events despite current treatments.
Area of Science:
- Cardiology
- Pharmacology
- Thrombosis research
Background:
- Coronary thrombosis, often linked to coronary artery disease, is a major cause of death and myocardial infarction.
- Antiplatelet drugs are crucial for managing acute coronary syndromes (ACS) and preventing recurrent events, especially after percutaneous coronary intervention.
- Despite advances, current antiplatelet therapies have limitations, necessitating further research into improved strategies.
Purpose of the Study:
- To review current and novel antiplatelet strategies for acute coronary syndromes (ACS).
- To discuss the clinical outcomes and risks associated with existing and emerging antiplatelet agents.
- To identify unmet needs in antiplatelet therapy for ACS patients.
Main Methods:
- Review of current literature on antiplatelet drugs used in ACS.
- Comparison of the efficacy and safety profiles of aspirin, clopidogrel, prasugrel, and ticagrelor.
- Exploration of novel antiplatelet agents targeting different pathways, including P2Y12 and protease-activated receptor-1.
Main Results:
- Newer oral P2Y12 antagonists (prasugrel, ticagrelor) offer more potent and consistent antiplatelet effects than clopidogrel, leading to improved clinical outcomes in ACS.
- These newer agents are associated with an increased risk of bleeding compared to older treatments.
- Platelet activation via pathways not inhibited by current drugs contributes to residual thrombotic events in some patients.
Conclusions:
- While novel oral P2Y12 antagonists have improved outcomes in ACS, a significant number of patients still suffer from thrombotic events.
- Emerging antiplatelet therapies include intravenous P2Y12 inhibitors and oral agents targeting the protease-activated receptor-1 pathway.
- Addressing unmet needs in antiplatelet therapy is essential for optimizing secondary prevention in ACS patients.
Introduction:
Coronary thrombosis is a frequent cause of death and myocardial infarction most often explained by superimposition of a platelet-rich thrombus on existing coronary artery disease. Therefore, antiplatelet drugs are essential in the treatment and secondary prevention of acute coronary syndromes (ACS) and during percutaneous coronary intervention. Several novel antiplatelet drugs are now available.
Areas Covered:
For several years, aspirin and clopidogrel remained the cornerstone of treatment for ACS. However, prasugrel and ticagrelor have a more consistent, faster-acting and more potent antiplatelet effect than clopidogrel, which translates into improved clinical outcomes, although at the expense of an increased bleeding risk. Importantly, some patients experience cardiovascular events despite current antiplatelet treatment, because platelet activation may occur via pathways not inhibited by these agents. Therefore, improved antiplatelet strategies are warranted.
Expert Opinion:
Despite undisputable benefits of current antiplatelet strategies, a considerable number of patients continue to experience adverse thrombotic events, although clinical outcomes have been improved with new oral P2Y₁₂ antagonists. New drugs have been developed, including intravenous P2Y₁₂ antagonists and oral antagonist targeting the protease-activated receptor-1 platelet activation pathway stimulated by thrombin. This review provides an overview of current and novel antiplatelet strategies and also discusses unmet needs related to antiplatelet therapy for ACS.
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