Antiplatelet strategies in patients undergoing interventions with acute coronary syndrome: introduction
Heart Center Bad Krozingen
Bad Krozingen
Germany
This supplement presents the proceedings of a scientific and clinical expert panel that was held on 8 March 2008 in Amsterdam, The Netherlands. The charge to the panel was to review and discuss the current and future challenges in the use of antiplatelet therapy in patients with acute coronary artery disease (CAD) who are undergoing percutaneous coronary intervention (PCI). This supplement will also review the currently available information on three of the antiplatelet agents in clinical development.
In the first article, Meinrad Gawaz reviews the evolving science of atherothrombotic disease with a focus on the physiology and pathophysiological role of platelets. We know that once platelets adhere to vessel walls, they become activated and start to degranulate proaggregation substances including adenosine diphosphate (ADP). The ability of ADP to stimulate platelet receptors expedites platelet aggregation and thrombus formation. This process can be inhibited by reversible and irreversible binding of antiplatelet compounds.
Marco Zimarino reviews the evidence supporting the use of oral antiplatelet agents in the long-term prevention of atherothrombotic disease. The Antithrombotic Trialists' Collaboration showed that aspirin reduces mortality in patients with vascular disease, and Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) showed that the addition of clopidogrel to aspirin provided clinical benefits beyond the use of aspirin alone. Subsequently, the results from a number of clinical trials helped to establish dual antiplatelet therapy with aspirin and clopidogrel as the gold standard for the treatment of patients with CAD. In spite of the proven clinical benefits; however, consideration has to be given to the potential for serious bleeding associated with antiplatelet agents.
Francisco Fernández-Avilés presents a European perspective on the use of antiplatelet agents in the treatment of atherothrombotic disease. CAD can progress to the formation of non-vulnerable plaque or to atherosclerotic plaque rupture leading to vessel occlusion and acute coronary syndromes (ACS). Antiplatelet agents have been used in each of these clinical settings to treat chronic stable CAD, non–ST-segment elevation (NSTE), or ST-elevation ACS. The European Society of Cardiology has recommended the use of specific antiplatelet agents based on the results of large comparative clinical trials. Aspirin and clopidogrel are recommended for all patients with ACS, while glycoprotein (GP) IIb/IIIa inhibitors provide benefit to patients with either NSTE–ACS or ST-elevation ACS.
Steen Husted reviews the benefits and risks associated with antiplatelet therapy. There have been a number of modifications in the dosing and duration of antiplatelet agents over the past 10 years, and these drugs are increasingly being used in dual- and triple-therapeutic regimens. Along with the improved efficacy of these combination therapies, comes an increased risk of major bleeding episodes. Professor Husted discusses some of the independent predictors for increased bleeding risk in patients and highlights the importance of following appropriate guidelines based on potential benefits and bleeding risk stratification.
Adnan Kastrati discusses whether changes are needed in the duration of antiplatelet therapy following intracoronary stenting. While the 2005 European Society of Cardiology guidelines on PCI and the 2005 American College of Cardiology/American Heart Association/Society of Cardiovascular Angiography and Interventions PCI guidelines differ somewhat on their recommendations for treatment durations, we know from a number of studies that the potential benefit of long-term dual antiplatelet therapy is contrasted by an increased risk of serious bleeding. Concerns about the rates of delayed stent thrombosis are also an important consideration in determining the optimal duration of dual antiplatelet therapy. Professor Kastrati reviews how ISAR-SAFE, ISAR-REBOUND, and ISAR-CAUTION will help to answer how long antiplatelet agents should be extended post-stent implantation, and also assist in defining the effect of abrupt versus tapered cessation of clopidogrel therapy.
Amadeo Betriu reviews the implications of a number of recently completed atherothrombotic trials on the management of patients with ACS. The cited trials in his article include OASIS 5-PCI, PCI-ACUITY, TRITON-TIMI-38, FINESSE, and CARESS-in-MI are discussed with respect to their design, and clinical outcomes, as well as the criticisms, limitations, and their relevance to practicing and interventional cardiologists.
In the final article, Marco Cattaneo reviews the pharmacology and clinical development of three new antiplatelet agents: prasugrel, a third-generation, oral thienopyridine; cangrelor, a chemical analogue of adenosine triphosphate and an intravenously administered potent direct platelet P2Y12 antagonist; and AZD6140 the first of a new class of antiplatelet agents that inhibits ADP-induced platelet aggregation at the level of the P2Y12 receptor. Only time will tell whether these new agents will demonstrate improved clinical outcomes in patients with ACS, as well as in those patients who are undergoing PCI.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||