Development of New Antithrombotic Regimens for Patients with Acute Coronary Syndrome
Sudhakar George1, Eunice N C Onwordi2, Amr Gamal3
1Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
Insights
Dual pathway inhibition using novel oral anticoagulants (NOACs) with antiplatelet therapy reduces ischemic events in acute coronary syndrome (ACS) patients. However, this approach increases bleeding risk, necessitating individualized treatment strategies.
Area of Science:
- Cardiology
- Pharmacology
- Thrombosis Research
Background:
- Acute coronary syndrome (ACS) patients need long-term antithrombotic therapy to prevent recurrent ischemic events.
- Current dual antiplatelet therapy (DAPT) with P2Y12 inhibitors and aspirin leaves a residual ischemic risk of approximately 10%.
- Novel oral anticoagulants (NOACs) offer a 'dual pathway' strategy by targeting both coagulation and platelet activation.
Purpose of the Study:
- To evaluate the efficacy and safety of 'triple therapy' (NOAC plus DAPT) for secondary prevention in ACS.
- To explore the role of NOACs in combination with P2Y12 inhibitors in reducing bleeding risk.
- To inform optimal, individualized treatment protocols for ACS secondary prevention.
Main Methods:
- The ATLAS ACS2 TIMI 51 trial investigated triple therapy with rivaroxaban (2.5 mg BID) plus DAPT.
- Clinical trials examined NOACs combined with P2Y12 inhibitors (with or without aspirin) in patients with atrial fibrillation undergoing PCI.
- Ongoing studies continue to assess NOAC-based strategies in ACS and related conditions.
Main Results:
- Triple therapy with rivaroxaban 2.5 mg BID demonstrated a reduction in ischemic events in ACS patients.
- An increased risk of bleeding was observed with the triple therapy approach.
- Studies in atrial fibrillation patients suggest potential for NOACs to reduce bleeding when combined with P2Y12 inhibitors.
Conclusions:
- Dual pathway inhibition strategies, including NOACs, show promise for reducing ischemic events in ACS.
- Balancing ischemic risk reduction with bleeding risk is crucial for effective ACS management.
- Individualized treatment approaches are essential, considering patient comorbidities.
Abstract:
Patients with acute coronary syndrome (ACS) require long-term antithrombotic intervention to reduce the risk of further ischemic events; dual antiplatelet therapy with a P2Y12 inhibitor and acetylsalicylic acid (ASA) is the current standard of care. However, pivotal clinical trials report that patients receiving this treatment have a residual risk of approximately 10% for further ischemic events. The development of non-vitamin K antagonist oral anticoagulants (NOACs) has renewed interest in a 'dual pathway' strategy, targeting both the coagulation cascade and platelet component of thrombus formation. In the phase III ATLAS ACS 2 TIMI 51 trial, a 'triple therapy' approach (NOAC plus dual antiplatelet therapy) showed reduced ischemic events with rivaroxaban 2.5 mg twice daily, albeit at an increased risk of bleeding. Two studies have investigated the role of NOACs in combination with a P2Y12 inhibitor, with or without ASA, in reducing bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention; two further studies are underway. Although these trials will help to inform optimal treatment protocols for secondary prevention of ACS, an individualized approach to treatment will be needed, taking account of the high frequency of co-morbid conditions found in this patient population.
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