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Beyond Aspirin and Clopidogrel: Is There a Need for Additional Antiplatelet Therapy in ACS?

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Abstract

Dual antiplatelet therapy with aspirin and clopidogrel is a well-established standard of care for patients with acute coronary syndromes. Whether there are other drug strategies or therapies that will achieve fewer ischemic events, and at the same time be associated with fewer bleeding complications, is a question recurrently asked. Finding the appropriate pharmacologic calibration of antiplatelet potency and applying such a pharmacodynamic effect to all patients has only been partially successful. The shadow of this one-size-fits-all dilemma is now being recast with the arrival of newer antiplatelet agents, which are attempting to decouple antithrombotic potency from bleeding liability. Novel antiplatelet agents that act faster and have more consistent pharmacokinetics and higher potency are steadily emerging. Additionally, newer agents that target unique sites, such as the thrombin receptor on platelets, are being studied in large-scale clinical trials. Each of these new agents has the potential to extend net clinical benefits beyond those provided by aspirin and clopidogrel.

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Abbreviations

BRIDGE:

Maintenance of Platelet Inhibition with Cangrelor After Discontinuation of Thienopyridines in Patients Undergoing Surgery

CHAMPION PLATFORM:

Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition

COGENT:

Clopidogrel and the Optimization of Gastrointestinal Events

CREDO:

Clopidogrel for the Reduction of Events During Observation

CURE:

Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events

CURRENT OASIS 7:

Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events—Seventh Organization to Assess Strategies in Ischemic Symptoms

ERASE-MI:

Elinogrel Before PCI to Optimize Reperfusion in Acute Myocardial Infarction

GRAVITAS:

Gauging Responsiveness with A Verify Now Assay-Impact on Thrombosis and Safety

INNOVATE-PCI:

Intravenous and Oral Administration of Elinogrel, a Selective and Reversible P2Y12-Receptor Inhibitor, Versus Clopidogrel to Evaluate Tolerability and Efficacy in Nonurgent Percutaneous Coronary Interventions Patients

ISAR--REACT:

Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment

LANCELOT-ACS:

Lesson from Antagonizing the Cellular Effect of Thrombin in Acute Coronary Syndromes

PLATO:

Platelet Inhibition and Patient Outcomes

TRA-PCI:

Thrombin Receptor Antagonist-Percutaneous Coronary Intervention

TRACER:

Thrombin Receptor Antagonist for Clinical Events Reduction

TRA2P-TIMI 50:

Thrombin-Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events

TRITON-TIMI 38:

Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction

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Disclosure

Conflicts of interest: L. Rajan: none; D.J. Moliterno: has received honoraria for serving as a consultant to Merck-Schering-Plough.

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  1. Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, 900 S. Limestone Street, 317 CT Wethington Building, Lexington, KY, 40536–0200, USA

    Lawrence Rajan & David J. Moliterno

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Correspondence to David J. Moliterno.

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Rajan, L., Moliterno, D.J. Beyond Aspirin and Clopidogrel: Is There a Need for Additional Antiplatelet Therapy in ACS?. Curr Cardiol Rep 13, 303–311 (2011). https://doi.org/10.1007/s11886-011-0195-0

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