scholarly journals The Role of Clopidogrel in 2020: A Reappraisal

2020 ◽  
Vol 2020 ◽  
pp. 1-12 ◽  
Author(s):  
Giuseppe Patti ◽  
Giuseppe Micieli ◽  
Claudio Cimminiello ◽  
Leonardo Bolognese
Keyword(s):  
Secondary Prevention ◽  
Antiplatelet Therapy ◽  
Minor Stroke ◽  
Clinical Settings ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Integral Role ◽  
Artery Disease ◽  
Ischemic Attack

Antiplatelet therapy is the mainstay of treatment and secondary prevention of cardiovascular disease (CVD), including acute coronary syndrome (ACS), transient ischemic attack (TIA) or minor stroke, and peripheral artery disease (PAD). The P2Y12 inhibitors, of which clopidogrel was the first, play an integral role in antiplatelet therapy and therefore in the treatment and secondary prevention of CVD. This review discusses the available evidence concerning antiplatelet therapy in patients with CVD, with a focus on the role of clopidogrel. In combination with aspirin, clopidogrel is often used as part of dual antiplatelet therapy (DAPT) for the secondary prevention of ACS. Although newer, more potent P2Y12 inhibitors (prasugrel and ticagrelor) show a greater reduction in ischemic risk compared with clopidogrel in randomized trials of ACS patients, these newer P2Y12 inhibitors are often associated with an increased risk of bleeding. Deescalation of DAPT by switching from prasugrel or ticagrelor to clopidogrel may be required in some patients with ACS. Furthermore, real-world studies of ACS patients have not confirmed the benefits of the newer P2Y12 inhibitors over clopidogrel. In patients with very high-risk TIA or stroke, short-term DAPT with clopidogrel plus aspirin for 21–28 days, followed by clopidogrel monotherapy for up to 90 days, is recommended. Clopidogrel monotherapy may also be used in patients with symptomatic PAD. In conclusion, there is strong evidence supporting the use of clopidogrel antiplatelet therapy in several clinical settings, which emphasizes the importance of this medication in clinical practice.

scholarly journals Dual Pathway Inhibition for Vascular Protection in Patients with Atherosclerotic Disease: Rationale and Review of the Evidence

2020 ◽  
Vol 120 (08) ◽  
pp. 1147-1158 ◽  
Author(s):  
Jeffrey Ian Weitz ◽  
Dominick J. Angiolillo ◽  
Tobias Geisler ◽  
Stefan Heitmeier
Keyword(s):  
Secondary Prevention ◽  
Antiplatelet Therapy ◽  
Standard Of Care ◽  
Atherosclerotic Disease ◽  
Vascular Protection ◽  
Coronary Syndrome ◽  
Plaque Disruption ◽  
Dual Pathway ◽  
Artery Disease ◽  
Pathway Inhibition

AbstractDespite advances in secondary prevention strategies in patients with cardiovascular disease, the residual risk of recurrent atherothrombotic events remains high. Dual-antiplatelet therapy is the standard of care for secondary prevention in patients with acute coronary syndrome (ACS), whereas single antiplatelet therapy, generally with aspirin, is the standard of care for secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. However, atherosclerotic plaque disruption not only triggers platelet activation but also results in thrombin generation because of tissue factor exposure. Therefore, blocking both pathways by combining antiplatelet therapy with an anticoagulant, or dual pathway inhibition (DPI), has the potential to be more effective than inhibiting either pathway alone. The benefit of DPI has been demonstrated in the ATLAS ACS 2-TIMI 51, COMPASS, and VOYAGER PAD trials, where the combination of rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin significantly reduced the risk of atherothrombotic events compared with aspirin across a broad range of patients, including those with recent ACS, those with chronic CAD and/or PAD, and patients with PAD who have undergone peripheral revascularization. This article provides the rationale for this regimen in more detail, including why the DPI regimen with the rivaroxaban vascular dose was developed for vascular protection in a broad spectrum of patients with atherosclerotic disease.

scholarly journals Features of Risk Stratification, Diagnosis and Secondary Prevention in Patients with Multifocal Arterial Disease. Part 1: Risk Stratification and Diagnosis

2021 ◽  
Vol 17 (1) ◽  
pp. 83-91
Author(s):  
V. G. Grachev ◽  
S. S. Vedenskaya ◽  
O. G. Smolenskaya
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Risk Stratification ◽  
Secondary Prevention ◽  
Lower Extremities ◽  
Arterial Disease ◽  
Chronic Coronary Artery Disease ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Artery Disease

Multifocal arterial disease is common in patients with atherosclerotic cardiovascular disease and is associated with an increased risk of cardiovascular complications and death. The possibility of improving the prognosis of patients with multifocal arterial disease is associated with a more efficient diagnosis of both the underlying disease and obstructive atherosclerotic lesions of other localizations and with a more intensive secondary prevention. According to observational studies, the presence of significant stenoses of the carotid arteries and, especially, lower extremities arterial disease can be predictorы of similar lesions in other vascular beds and their detection with screening methods available in clinical practice allows improvement of the diagnosis in patients with suspected coronary artery disease. On the other hand, screening of lower extremities artery diseases in patients with acute coronary syndrome can clarify indications for the use of invasive diagnostic and treatment strategy, in patients with chronic coronary artery disease it can justify more aggressive approaches to secondary prevention.

scholarly journals Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients With Coronary Artery Disease and Diabetes Mellitus

Circulation ◽  
2020 ◽  
Vol 142 (22) ◽  
pp. 2172-2188
Author(s):  
Davide Capodanno ◽  
Dominick J. Angiolillo
Keyword(s):  
Diabetes Mellitus ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Secondary Prevention ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Thrombotic Risk ◽  
Increased Risk ◽  
Artery Disease

Patients with diabetes mellitus (DM) are characterized by enhanced thrombotic risk attributed to multiple mechanisms including hyperreactive platelets, hypercoagulable status, and endothelial dysfunction. As such, they are more prone to atherosclerotic cardiovascular events than patients without DM, both before and after coronary artery disease (CAD) is established. In patients with DM without established CAD, primary prevention with aspirin is not routinely advocated because of its increased risk of major bleeding that largely offsets its ischemic benefit. In patients with DM with established CAD, secondary prevention with antiplatelet drugs is an asset of pharmacological strategies aimed at reducing the risk of atherosclerotic cardiovascular events and their adverse prognostic consequences. Such antithrombotic strategies include single antiplatelet therapy (eg, with aspirin or a P2Y 12 inhibitor), dual antiplatelet therapy (eg, aspirin combined with a P2Y 12 inhibitor), and dual-pathway inhibition (eg, aspirin combined with the vascular dose of the direct oral anticoagulant rivaroxaban) for patients with chronic ischemic heart disease, acute coronary syndromes, and those undergoing percutaneous coronary intervention. Because of their increased risk of thrombotic complications, patients with DM commonly achieve enhanced absolute benefit from more potent antithrombotic approaches compared with those without DM, which most often occurs at the expense of increased bleeding. Nevertheless, studies have shown that when excluding individuals at high risk for bleeding, the net clinical benefit favors the use of intensified long-term antithrombotic therapy in patients with DM and CAD. Several studies are ongoing to establish the role of novel antithrombotic strategies and drug formulations in maximizing the net benefit of antithrombotic therapy for patients with DM. The scope of this review article is to provide an overview of current and evolving antithrombotic strategies for primary and secondary prevention of atherosclerotic cardiovascular events in patients with CAD and DM.

scholarly journals PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE AND ANTIPLATELET THERAPY. CLINICAL LECTURE

2017 ◽  
pp. 89-93
Author(s):  
L. O. Minushkina
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Primary Prevention ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Antiplatelet Agent ◽  
Term Therapy ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Artery Disease

Today, treatment with low doses of acetylsalicylic acid (ASA) (alone or in combination with other antiplatelet drugs) is the key element in the secondary prevention of coronary artery disease. Long-term therapy with low-dose ASA is recommended to patients with stable coronary artery disease, patients after acute coronary syndrome with or without ST segment elevation, and after revascularization. [1–3] The need for antithrombotic therapy in the primary prevention of cardiovascular events raises many questions. The currently available guidelines are contradictory – from complete denial of the need for antiplatelet therapy to designation of the specific groups of patients for whom ASA treatment is recommended. [4, 5] Findings of clinical trials underlie those contradictory opinions. ASA is the only antiplatelet agent the administration of which is debated for primary prevention. Administration of ASA in primary prevention usually results in a reduced risk of cardiovascular complications, but the positive effect is largely offset by an increased risk of bleeding, particularly gastrointestinal. Therefore, the challenge is in the selection of patients for whom the benefit from antithrombotic therapy could outweigh the risks associated with bleeding. Risk scores are commonly used to assess the risk of complications.

Antithrombotic Therapy in Lower Extremity Artery Disease

2020 ◽  
Vol 18 (3) ◽  
pp. 215-222 ◽  
Author(s):  
Mislav Vrsalovic ◽  
Victor Aboyans
Keyword(s):  
Lower Extremity ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Cardiovascular Outcomes ◽  
Lower Limbs ◽  
Stent Type ◽  
Increased Risk ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

scholarly journals Ischemic and bleeding risk stratification in diabetic patients after acute coronary syndrome based on insulin requirement

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
I Cavallari ◽  
E Sagazio ◽  
E Antonucci ◽  
P Calabro' ◽  
F Gragnano ◽  
...  
Keyword(s):  
Insulin Therapy ◽  
Antiplatelet Therapy ◽  
Clinical Benefit ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Diabetic Patients ◽  
Coronary Syndrome ◽  
Diabetes Status ◽  
Increased Risk ◽  
Net Clinical Benefit

Abstract Background Diabetes is a known risk factor for a first or recurrent cardiovascular event, however, its association with an increased risk of bleeding is controversial. To date, no study has explored the prognostic weight of insulin therapy in the setting of ACS. Purpose To investigate the differential role of insulin versus no insulin therapy on ischemic and bleeding risks in patients with diabetes and ACS. Methods START-ANTIPLATELET is a prospective, real-world multicenter registry including consecutive patients admitted for ACS. For the purpose of this analysis, patients were stratified according to diabetes status and insulin therapy. We compared 1-year rates of major adverse cardiovascular events, a composite of cardiovascular death, myocardial infarction and stroke, and of any bleeding, according to diabetes status (no diabetes, diabetes not on insulin therapy, diabetes on insulin therapy). In addition, we evaluated the net clinical benefit of dual antiplatelet therapy with the newer P2Y12 inhibitors (ticagrelor or prasugrel) vs dual antiplatelet therapy with clopidogrel according to diabetes status. Results In an overall population of 907 patients, 198 had diabetes, 10.6% of whom were on insulin. From non-diabetic patients to diabetic patients not on insulin and diabetic patients on insulin there was a stepwise decrease of MACE-free survival (log-rank p 0.039) with incidence of events at 1 year being 3.8%, 6.8% (adjusted p vs no diabetes 0.49) and 12.5% (adjusted p vs no diabetes 0.047), respectively (Figure, panel A). The rates of any bleeding were higher in patients on insulin (20.8% vs 8.8% in those without diabetes and 5.8% in diabetic patients not receiving insulin; log-rank p 0.028; Figure, panel B). Multivariable analysis demonstrated an almost 5-fold increase of any bleeding in diabetic patients with vs without insulin (OR 4.98, 95% CI 1.46–16.92; p=0.010). In the overall population, the incidence of the net composite endpoint including MACE or major bleeding with the use of ticagrelor/prasugrel on top of aspirin was significantly lower compared to use of clopidogrel (4.7% vs 8.4%; OR 0.54, 95% CI 0.30–0.94, p=0.031). This net clinical benefit in patients receiving a newer P2Y12 inhibitor was regardless of the diabetes status (p for interaction 0.48). Conclusions In this cohort of ACS patients, the presence of diabetes stratified by insulin therapy was associated with a graded increase in the 1-year rates of MACE. Conversely, insulin therapy significantly contributed to the overall increase of bleeding risk in diabetes. Funding Acknowledgement Type of funding source: None

scholarly journals Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

2020 ◽  
pp. svn-2019-000319
Author(s):  
Peng Wang ◽  
Mengyuan Zhou ◽  
Yuesong Pan ◽  
Xia Meng ◽  
Xingquan Zhao ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
National Institutes Of Health ◽  
Minor Stroke ◽  
Post Hoc Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Ischemic Attack ◽  
Post Hoc

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy (DAPT) and aspirin have different efficacies on outcomes in patients with minor stroke.MethodsA post hoc analysis of patients with acute minor stroke treated with intravenous t-PA within 4.5 hours from a nationwide multicentric electronic medical record and patients with acute minor stroke treated with DAPT and aspirin from the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack Database. Minor stroke was defined by a score of 0–3 on the National Institutes of Health Stroke Scale at randomisation. Favourable functional outcome (defined as modified Rankin Scale (mRS) score of 0–1 or 0–2 at 3 months).ResultsCompared with those treated with intravenous t-PA, no significant association with 3-month favourable functional outcome (defined as mRS score of 0–1) was found neither in patients treated with aspirin (87.8% vs 89.4%; OR, 0.83; 95% CI, 0.46 to 1.50; p=0.53) nor those treated with DAPT (87.4% vs 89.4%; OR, 0.84; 95% CI, 0.46 to 1.52; p=0.56). Similar results were observed for the favourable functional outcome defined as mRS score of 0–2 at 3 months.ConclusionsIn our study, no significant advantage of intravenous t-PA over DAPT or aspirin was found. Due to insufficient sample size, our study is probably unable to draw such a conclusion that that intravenous t-PA was superior or non-superior to DAPT.

Sign in / Sign up

Export Citation Format

Share Document