Antiplatelet Therapy for Percutaneous Coronary Intervention: Something Old and Something New
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SECONDARY PREVENTION AND INTERVENTION (D. STEINBERG, SECTION EDITOR)
Antiplatelet Therapy for Percutaneous Coronary Intervention: Something Old and Something New Michael A. Gaglia, Jr. 1
Published online: 10 February 2017 # Springer Science+Business Media New York 2017
Abstract Purpose of Review Antiplatelet therapy for patients undergoing percutaneous coronary intervention has rapidly evolved over the last 10 years, often outpacing clinical guidelines. This review appraises recent clinical trials within the context of landmark trials in interventional cardiology, and offers a framework for the integration of recent trials into clinical practice. Recent Findings This review interprets recent evidence regarding the following: (1) aspirin and the most effective dose; (2) the role of the newer, more potent P2Y12 inhibitors prasugrel, ticagrelor, and cangrelor; (3) an appraisal of the evolving paradigm for duration of dual antiplatelet therapy; and (4) perspective on the role of glycoprotein IIb/IIIa inhibitors in the era of routine and potent P2Y12 inhibition. Summary The newer and more potent P2Y12 inhibitors, as well as a more nuanced understanding of mainstays of treatment like aspirin, offer the promise of maximizing ischemic benefit and minimizing bleeding in patients undergoing percutaneous coronary intervention.
Keywords Aspirin . Clopidogrel . Prasugrel . Ticagrelor . Cangrelor . Platelet aggregation inhibitors . Percutaneous coronary intervention
Introduction Antiplatelet therapy is a cornerstone in the treatment of patients undergoing percutaneous coronary intervention (PCI), regardless of clinical presentation. The rationale for antiplatelet therapy, however, is based upon three distinct pathophysiologic mechanisms that occur in patients with obstructive coronary artery disease (CAD). The first is the disruption of endothelium that necessarily occurs with balloon angioplasty and stenting. The second is the interaction of platelets with a foreign substance, typically the metallic scaffold or its polymeric coating. The third is the rupture or erosion of an unstable plaque , typically occurring as an acute coronary syndrome (ACS). These events, although different in etiology, end in platelet activation and aggregation; this framework is thus useful to conceptualize decisions regarding antiplatelet therapy. Ultimately, antiplatelet therapy aims to minimize both periprocedural and remote events that lead to coronary ischemia and mortality. The purpose of this review is to place recent evidence for antiplatelet therapy, for both elective and ACS indications, within the context of both landmark trials and an overall approach to the patient with CAD requiring PCI. The drugs discussed in this review are summarized in Table 1.
Aspirin This article is part of the Topical Collection on Secondary Prevention and Intervention * Michael A. Gaglia, Jr. [email protected] 1
Division of Cardiology, University of New Mexico School of Medicine, 1 University of New Mexico, MSC 10-5550, Albuquerque, NM 87131, USA
Acet
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