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Antiplatelet Agent Choice and Platelet Function Testing in CKD

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Kidney Disease in the Cardiac Catheterization Laboratory

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Abstract

Platelets play a pivotal role during arterial thrombotic event occurrences in patients undergoing percutaneous coronary intervention (PCI). Inhibition of the platelet COX-1 enzyme by aspirin and the P2Y12-ADP interaction by P2Y12 receptor inhibitors is a major pharmacologic strategy to prevent acute as well as long-term thrombotic event occurrences following PCI. Clopidogrel, the most widely used P2Y12 receptor inhibitor, is associated with wide response variability, and one in three patients exhibit no or negligible antiplatelet response. High on-treatment platelet reactivity (HPR) during clopidogrel therapy is a strong predictor for post-PCI ischemic event occurrences. The concept of a “therapeutic window” of P2Y12 receptor reactivity associated with both ischemic event occurrence (upper threshold) and bleeding risk (lower threshold) has been proposed. These observations provided a strong rationale to measure the platelet response to ADP during P2Y12 receptor inhibitor therapy and to personalize antiplatelet therapy. Potent P2Y12 receptor inhibitors, prasugrel and ticagrelor, are credible alternatives to clopidogrel. Chronic kidney disease (CKD) is commonly present in patients undergoing PCI and is associated with an increased risk for both thrombosis and bleeding. The effect of CKD on platelet function remains controversial. Studies in patients with CKD on dual antiplatelet therapy have demonstrated an elevated risk for HPR, and some studies correlated HPR to clinical outcomes. At this time the guidelines do not suggest a difference in antiplatelet therapy in patients undergoing PCI with and without CKD.

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Disclosures

Dr. Gurbel reports receiving grants from the National Institutes of Health, Bayer, Medicure, Instrumentation Labs, Haemonetics, Amgen, Idorsia, Ionis, Haemonetics, Janssen, and Merck; receiving honoraria and payment for lectures, consultations including services on speakers’ bureaus from Bayer, Janssen, Merck, UpToDate, and Medicure; and holding patents in the area of personalized antiplatelet therapy and interventional cardiology.

Dr. Tantry reports receiving honoraria from AstraZeneca, UpToDate, and Medicure.

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Authors and Affiliations

  1. Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA

    Udaya S. Tantry, Amit Rout & Paul A. Gurbel

  2. Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Rahul Chaudhary

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  1. Udaya S. Tantry
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  2. Amit Rout
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  3. Rahul Chaudhary
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  4. Paul A. Gurbel
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Correspondence to Paul A. Gurbel .

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Editors and Affiliations

  1. Einstein Medical Center/Thomas Jefferson University, Department of Medicine/Nephrology, Philadelphia, PA, USA

    Janani Rangaswami

  2. UIC/Advocate Christ Medical Center, Department of Medicine, Chicago, Il, USA

    Edgar V. Lerma

  3. Baylor University Medical Center, Baylor Heart and Vascular Hospital, Department of Internal Medicine, Texas A & M College of Medicine, Division of Cardiology, Dallas, TX, USA

    Peter A. McCullough

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Tantry, U.S., Rout, A., Chaudhary, R., Gurbel, P.A. (2020). Antiplatelet Agent Choice and Platelet Function Testing in CKD. In: Rangaswami, J., Lerma, E., McCullough, P. (eds) Kidney Disease in the Cardiac Catheterization Laboratory . Springer, Cham. https://doi.org/10.1007/978-3-030-45414-2_6

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  • DOI: https://doi.org/10.1007/978-3-030-45414-2_6

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