scholarly journals Clopidogrel as a part of double disaggregant therapy in ACS: a reasonable choice in complex clinical situations

2019 ◽  
pp. 20-29 ◽  
Author(s):  
V. V. Kashtalap ◽  
O. L. Barbarash
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Clinical Case ◽  
Correct Selection ◽  
Coronary Syndrome ◽  
Hemorrhagic Events ◽  
Register Studies ◽  
Reasonable Choice ◽  
Selection Of

Based on the recommendations of the European Heart Society and the results of clinical and register studies, the article highlights the complex issues that arise when prescribing antiplatelet therapy in patients with acute coronary syndrome, including with concomitant atrial fibrillation (AF); the promising strategies for managing the risk of ischemic and hemorrhagic events are described. Also a clinical case of a patient with acute coronary syndrome and AF is presented, illustrating the objective complexity of correct selection of antiplatelet therapy in such patients.

scholarly journals Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome

2020 ◽  
Vol 9 (7) ◽  
pp. 2020
Author(s):  
Wilbert Bor ◽  
Diana A. Gorog
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Combination Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome ◽  
Antithrombotic Efficacy ◽  
Selection Of ◽  
Made In

Acute coronary syndrome and atrial fibrillation are both common and can occur in the same patient. Combination therapy with dual antiplatelet therapy and oral anticoagulation increases risk of bleeding. Where the two conditions coexist, careful consideration is needed to determine the optimal antithrombotic treatment to reduce the risks of future ischaemic events associated with both conditions. Choices can be made in intraprocedural anticoagulation, type and dosing of oral anticoagulant, duration of combination therapy, and selection of P2Y12 inhibitor including genetic testing. This review article provides an overview of the available evidence to support clinicians in finding the delicate balance between antithrombotic efficacy and bleeding risk in patients with acute coronary syndrome and atrial fibrillation.

Economic Evaluations of CYP2C19 Genotype-Guided Antiplatelet Therapy Compared to the Universal Use of Antiplatelets in Patients With Acute Coronary Syndrome: A Systematic Review

2020 ◽  
Vol 25 (3) ◽  
pp. 201-211
Author(s):  
Sawsan AlMukdad ◽  
Hazem Elewa ◽  
Daoud Al-Badriyeh
Keyword(s):  
Systematic Review ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Cost Effective ◽  
Economic Evaluations ◽  
Cyp2c19 Genotype ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Selection Of ◽  
Guided Therapy

Background and Objectives: Clopidogrel is widely used after the percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and requires activation by cytochrome P450 (CYP), primarily CYP2C19. Patients with CYP2C19 loss-of-function alleles are at increased risk of major adverse cardiovascular events, while more expensive novel antiplatelet agents (ticagrelor and prasugrel) are unaffected by the CYP2C19 mutations. This systematic review aims to answer the question about whether overall evidence supports the genotype-guided selection of antiplatelet therapy as a cost-effective strategy in post-PCI ACS. Methods: A systematic literature search of PubMed, EMBASE, EconLit, and PharmGKB was done to identify all the economic evaluations related to genotype-guided therapy compared to the universal use of antiplatelets in ACS patients. Quality of Health Economic Studies tool was used for quality assessment. Results: The search identified 13 articles, where genotype-guided treatment was compared to universal clopidogrel, ticagrelor, and/or prasugrel. Six studies showed that genotype-guided therapy was cost-effective compared to universal clopidogrel, while 5 studies showed that it was dominant. One study specified that genotype-guided with ticagrelor is cost-effective only in both CYP2C19 intermediate and poor metabolizers. Genotype-guided therapy was dominant when compared to universal prasugrel, ticagrelor, or both in 5, 1, and 3 studies, respectively. Only 2 studies reported that universal ticagrelor was cost-effective compared to genotype-guided treatment. All the included articles had good quality. Conclusion: Based on current economic evaluations in the literature, implementing CYP2C19 genotype-guided therapy is a cost-effective approach in guiding the selection of medication in patients with ACS undergoing PCI.

Antithrombotic therapy: triple therapy or triple threat?

Hematology ◽  
2012 ◽  
Vol 2012 (1) ◽  
pp. 547-552 ◽  
Author(s):  
Jessica Mega ◽  
Edward T. Carreras
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Observational Studies ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Risks And Benefits ◽  
Percutaneous Coronary ◽  
Pharmacokinetic Properties

Abstract Antithrombotic therapy plays an essential role in the management of some of the most common and morbid medical conditions. Triple oral antithrombotic therapy (TOAT) is defined as the administration of both therapeutic oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT) to patients with indications for both treatments. The current societal guidelines regarding TOAT are derived from observational studies and some trials of the use of warfarin in addition to antiplatelet therapy in patients with atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention. The general apprehension to administer TOAT is due to the heightened concern for bleeding, rendering warfarin's pharmacokinetic properties concerning. Newer anticoagulant agents may serve as appealing alternatives, and further investigations are warranted. The results of the recent trials that have studied the use of these agents in atrial fibrillation and acute coronary syndrome offer some useful applications to TOAT. Ultimately, selecting the most favorable antithrombotic strategy is going to involve weighing the risks and benefits for each patient.

Results of Register in Patients with Acute Coronary Syndrome and Atrial Fibrillation Receiving Rivaroxaban

Kardiologiia ◽  
2021 ◽  
Vol 61 (6) ◽  
pp. 52-58
Author(s):  
O. А. Baturina ◽  
D. A. Andreev ◽  
D.i A. Sychev ◽  
D. F. Mesitskaya ◽  
S. V. Andranovich ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Composite Endpoint ◽  
Medical Attention ◽  
Antiplatelet Treatment ◽  
Ischemic Cerebrovascular Disease ◽  
Coronary Syndrome ◽  
Hemorrhagic Complications ◽  
Risk Patients

Aim      To evaluate outcomes in patients with acute coronary syndrome and atrial fibrillation who receive rivaroxaban and the patients’ compliance with the antithrombotic therapy.Material and methods  The study was performed from October 2017 through December 2019 and included 129 patients. Events between the discharge from the hospital and 12 months of follow-up were recorded. The primary endpoint was development of major, minor or requiring medical attention bleeding according to the TIMI scale. The secondary endpoint was a combination of recurrent myocardial infarction, nonfatal acute ischemic cerebrovascular disease, nonfatal systemic embolism, stent thrombosis, and cardiovascular mortality.Results 32 (24.8%) patients early terminated the antiplatelet treatment and 22 (17.1%) patients terminated the rivaroxaban treatment. 26 (20.2 %) patients had hemorrhagic complications. The highest incidence of hemorrhage was observed within the first 2 months after the discharge. None of the bleedings was fatal. Composite endpoint events were observed in 24 (18.6 %) patients, including 14 (10.9 %) who died from cardiovascular causes.Conclusion      The compliance with the antiplatelet therapy was insufficient. The incidence of hemorrhagic complications was relatively high; minor and requiring medical attention hemorrhages mostly contributed to the structure of these complications. The observed incidence of recurrent ischemic events associated with a high mortality presents a more serious problem compared to hemorrhagic complications of the combination antiplatelet therapy and warrants a more aggressive tactics of the antiplatelet treatment in high-risk patients.

scholarly journals Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome—Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy?

2020 ◽  
Vol 9 (8) ◽  
pp. 2673
Author(s):  
Ugo Limbruno ◽  
Francesco De Sensi ◽  
Alberto Cresti ◽  
Andrea Picchi ◽  
Fabio Lena ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Dual Antiplatelet Therapy ◽  
Controlled Trial ◽  
Complex Situation ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
Number Of Patients

The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk—cardioembolic, coronary, and hemorrhagic—has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y12 inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y12 inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF–ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA2DS2VASc score 2–4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial.

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