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Published on: March 15, 2022
Antithrombotic therapy for patients with STEMI undergoing primary PCI
Francesco Franchi1, Fabiana Rollini1, Dominick J Angiolillo1
1University of Florida College of Medicine-Jacksonville, Division of Cardiology-ACC Building 5th floor, 655 West 8th Street, Jacksonville, Florida 32209, USA.
Insights
Optimizing antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial for ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). This review covers current therapies, trial results, and clinical practice recommendations for better outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Thrombosis Research
Background:
- Antithrombotic therapy is essential for ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).
- Current intravenous agents include unfractionated heparin, low-molecular-weight heparin, bivalirudin, glycoprotein IIb/IIIa inhibitors, and cangrelor.
- Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is standard, with newer agents like prasugrel and ticagrelor offering improved efficacy over clopidogrel.
Purpose of the Study:
- To review current antithrombotic therapies for STEMI patients undergoing PPCI.
- To analyze pivotal clinical trial data and guideline implications.
- To provide recommendations for clinical practice regarding antithrombotic strategies.
Main Methods:
- Comprehensive literature review of antithrombotic agents and clinical trials.
- Analysis of intravenous and oral antiplatelet and anticoagulant therapies.
- Evaluation of treatment outcomes and adverse events in STEMI patients.
Main Results:
- Prasugrel and ticagrelor demonstrate superior antiplatelet effects and clinical outcomes compared to clopidogrel in PPCI.
- Alternative thrombotic pathways necessitate exploring novel strategies targeting thrombin and coagulation factors.
- Oral anticoagulants like rivaroxaban and thrombin receptor antagonists like vorapaxar are being investigated.
Conclusions:
- Current first-line antithrombotic therapy for STEMI undergoing PPCI involves dual antiplatelet therapy with newer P2Y12 inhibitors.
- Addressing residual ischemic events may require targeting alternative pathways, including direct thrombin inhibition or receptor antagonism.
- Evidence-based recommendations guide the optimal use of these therapies to improve patient outcomes.
Abstract:
Antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Intravenous anticoagulant drugs available for PPCI include the indirect thrombin inhibitors unfractionated heparin and low-molecular-weight heparin, and the direct thrombin inhibitor bivalirudin. Intravenous antiplatelet drugs mainly include glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor. Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI. Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes. Therefore, these agents are the first-line treatment in PPCI. However, patients can still experience adverse ischaemic events, which might be in part attributed to alternative pathways triggering thrombosis. Thrombin has an important role, suggesting the need for strategies directly targeting circulating thrombin or other factors of the coagulation cascade, such as oral anticoagulants (rivaroxaban), and the thrombin receptor on the platelet membrane (vorapaxar). In this Review, we provide an overview of currently available antithrombotic therapies used in patients with STEMI undergoing PPCI, results from pivotal clinical trials and their implications for guidelines, as well as recommendations for clinical practice.
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