Antiplatelet Agents for the Treatment and Prevention of Atherothrombosis

Perspective:

The following are 10 points to remember about antiplatelet agents for the treatment and prevention of atherothrombosis:

1. Platelets are vital components of normal hemostasis and key participants in atherothrombosis by virtue of their capacity to adhere to injured blood vessels and to accumulate at sites of injury.

2. The present document intends to provide practicing physicians with an updated instrument to guide their choice of the most suitable antiplatelet strategy for the individual patient at risk, or with different clinical manifestations, of atherothrombosis.

3. Aspirin once daily is recommended in clinical conditions in which antiplatelet prophylaxis has a favorable benefit/risk profile. The available evidence supports daily doses of aspirin in the range of 75-100 mg for the long-term prevention of serious vascular events in high-risk patients, including those with acute coronary syndrome (ACS) and those undergoing percutaneous coronary intervention (PCI).

4. The currently available trial results do not seem to justify the routine use of aspirin in all apparently healthy individuals above a moderate level of coronary risk, but without pre-existing vascular disease.

5. Clopidogrel, 75 mg daily, is an appropriate alternative for patients with coronary, cerebrovascular, or peripheral arterial disease who cannot tolerate low-dose aspirin.

6. The improved efficacy of prasugrel over clopidogrel may be exploited in the setting of ST-segment elevation myocardial infarction (STEMI) referred for primary PCI or after coronary angiography in patients with non−ST-elevation (NSTE)-ACS undergoing PCI. The use of prasugrel should also be considered in patients who develop stent thrombosis despite aspirin and clopidogrel therapy.

7. The combination of low-dose aspirin and extended-release dipyridamole (200 mg bid) is considered an acceptable option for patients with noncardioembolic cerebral ischemic events; however, there is no basis to recommend this combination in patients with ischemic heart disease.

8. Ticagrelor provides superior prevention of death and recurrent MI compared with clopidogrel when used in patients with STEMI planned for primary PCI or moderate-to-high-risk NSTE-ACS and is therefore recommended in these patients other than those with prior history of intracranial hemorrhage or active pathological bleeding that cannot be controlled by local measures.

9. Currently, the place of systematic glycoprotein IIb/IIIa blockade for primary PCI is uncertain within the context of concomitant antithrombotic treatment.

10. The practice of withdrawing antiplatelet therapy 7–10 days before surgery/endoscopy/biopsy is undergoing critical reappraisal. A risk-benefit assessment should be performed, based on the patient’s thrombotic risk of stopping therapy against the hemorrhagic risk of continuing single or dual antiplatelet therapy.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Vascular Medicine

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Platelet Aggregation Inhibitors, Peripheral Arterial Disease, Percutaneous Coronary Intervention


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