Consensus and Update on the Definition of On-Treatment Platelet Reactivity to ADP Associated With Ischemia and Bleeding

Perspective:

The following are 10 points to consider from this review:

1. Dual antiplatelet therapy with aspirin and a P2Y12 antagonist is effective in preventing ischemic events following acute coronary syndrome (ACS) and especially in the 1-2 months following percutaneous coronary intervention (PCI).

2. Several studies have demonstrated an association between high platelet reactivity to ADP (HPR) and ischemic events following PCI.

3. The utility of personalized antiplatelet therapy, based on platelet function testing (PFT) to improve prognosis, has not been supported by large randomized trials.

4. While the ARCTIC and GRAVITAS trials suggest that HPR represents a nonmodifiable risk factor, it may be that HPR was not modified enough with higher-dose clopidogrel, or that the absolute risk of the population studied was too low to detect added benefit.

5. Clinical events may be higher in routine practice compared to selected patients enrolled in clinical trials; thus, personalized therapy may play a greater role in clinical practice.

6. Although the utility of PFT in guiding therapeutic strategies remains to be proven, PFT may be helpful in the identification of high-risk patients.

7. PFT may be appropriate in high-risk clopidogrel patients with a history of stent thrombosis and in patients with left ventricular dysfunction, complex anatomy, high body mass index, or diabetes.

8. A risk algorithm that includes PFT, along with other biomarkers and clinical factors, may improve risk prediction and the prognostic utility of personalized antiplatelet therapy.

9. Some studies have indicated that a low platelet reactivity is associated with an increased risk of bleeding.

10. New clinical trials are needed to validate the concept of a therapeutic window for P2Y12 antagonists, guided by PFT, to maximize risk-to-benefit ratio of antiplatelet strategies.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, ACS and Cardiac Biomarkers, Interventions and ACS

Keywords: Prognosis, Acute Coronary Syndrome, Platelet Aggregation Inhibitors, Biological Markers, Platelet Function Tests, Troponin I, Percutaneous Coronary Intervention


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