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Clinical Implications of "Tailored" Antiplatelet Therapy in Patients With Chronic Total Occlusion
Maria Grazia De Gregorio1,2, Rossella Marcucci1,2, Angela Migliorini1
1Cardiovascular Department Azienda Ospedaliero-Universitaria Careggi Florence Italy.
Insights
High platelet reactivity (HPR) after percutaneous coronary intervention is linked to poorer outcomes. Tailored antiplatelet therapy with newer agents improves survival in patients with chronic total occlusion and HPR.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- Clopidogrel nonresponsiveness, indicated by high platelet reactivity (HPR), is a significant prognostic factor post-percutaneous coronary intervention (PCI).
- Newer P2Y12 inhibitors like prasugrel and ticagrelor offer superior platelet inhibition compared to clopidogrel, becoming first-line treatments for acute coronary syndrome.
- Assessing the impact of HPR and the benefit of tailored antiplatelet strategies is crucial for patients undergoing chronic total occlusion (CTO) PCI.
Purpose of the Study:
- To evaluate the prognostic significance of high platelet reactivity (HPR) in patients with chronic total occlusion undergoing percutaneous coronary intervention (CTO-PCI).
- To determine the clinical benefit of adjusting antiplatelet therapy based on platelet function testing in this patient cohort.
Main Methods:
- Analysis of data from the Florence CTO-PCI registry, including 1101 patients with available platelet function data.
- Platelet function was assessed using light transmission aggregometry, defining HPR as an adenosine diphosphate (ADP) test result ≥70%.
- Long-term cardiac survival was the primary endpoint, with patients stratified into optimal platelet reactivity (<70% ADP) and HPR groups.
Main Results:
- Patients with optimal platelet reactivity demonstrated significantly higher three-year survival (95.3%) compared to those with HPR (86.2%; P<0.001).
- In HPR patients, switching to newer P2Y12 inhibitors achieved deeper platelet inhibition (46%) and survival comparable to the optimal group.
- Conversely, HPR patients remaining on clopidogrel without therapy adjustment faced increased cardiac mortality (HR 2.37; P=0.003).
Conclusions:
- High platelet reactivity (HPR) in patients undergoing CTO-PCI is a modifiable prognostic marker.
- Utilizing newer antiplatelet agents to achieve deeper platelet inhibition can improve clinical outcomes in HPR patients.
- A tailored antiplatelet therapy approach, guided by platelet function testing, is beneficial for high-risk CTO-PCI patients.
Abstract:
Background Clopidogrel nonresponsiveness is a prognostic marker after percutaneous coronary intervention. Prasugrel and ticagrelor provide a better platelet inhibition and represent the first-line antiplatelet treatment in acute coronary syndrome. We sought to assess the prognostic impact of high platelet reactivity (HPR) and the potential clinical benefit of a "tailored" escalated or changed antiplatelet therapy in patients with chronic total occlusion. Methods and Results From Florence CTO-PCI (chronic total occlusion-percutaneous coronary intervention) registry, platelet function assessed by light transmission aggregometry, was available for 1101 patients. HPR was defined by adenosine diphosphate test ≥70% and optimal platelet reactivity by adenosine diphosphate test <70%. The endpoint of the study was long-term cardiac survival. Patients were stratified according to light transmission aggregometry results: optimal platelet reactivity (82%) and HPR (18%). Means for the adenosine diphosphate test were 44±16% versus 77±6%, respectively. Three-year survival was significantly higher in the optimal platelet reactivity group compared with HPR patients (95.3±0.8% versus 86.2±2.8%; P<0.001). With the availability of new P2Y12 inhibitors, a deeper platelet inhibition (46±17%) and similar survival to the optimal platelet reactivity group were achieved in patients with HPR on clopidogrel therapy after escalation. Conversely, HPR on clopidogrel therapy "not switched" was associated with cardiac mortality (hazard ratio 2.37; P=0.003) after multivariable adjustment. Conclusions HPR on treatment could be a modifiable prognostic marker by new antiaggregants providing a deeper platelet inhibition associated with clinical outcome improvement in complex chronic total occlusion patients. A "tailored" antiplatelet therapy, also driven by the entity of platelet inhibition, could be useful in these high risk setting patients.
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