Antiplatelet therapy to support PCI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Aslam, M.B.B.S[2]

Overview

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI.[1][2][3][4][5] However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI.

Antiplatelet Therapy to Support PCI

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI.[1][2][3][4][5] However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI. It is a trial designed for superiority comparing downstream therapy over upstream therapy in terms of NACE ( net adverse cardic effect) and risk of major bleeding(BARC 3, 4 and 5). Another endpoint considered in the trial is non inferiority comparison between prasugrel and ticagrelor in terms of potency of the drug for clinical benefit and NACE.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[6]

Oral Antiplatelet Therapy (DO NOT EDIT)[6]

Class I
"1. Patients already taking daily aspirin therapy should take 81 mg to 325 mg before PCI.[7][8][9] (Level of Evidence: B)"
"2. Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before PCI.[7][9] (Level of Evidence: B)"
"3. After PCI, use of aspirin should be continued indefinitely.[10][11][12][13] (Level of Evidence: A)"
"4. A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting.[1][2][3][4][5] (Level of Evidence: A) Options include:
a. Clopidogrel 600 mg (ACS and non-ACS patients).[1][2][3](Level of Evidence: B)
b. Prasugrel 60 mg (ACS patients).[4] (Level of Evidence: B)
c. Ticagrelor 180 mg (ACS patients).[5] (Level of Evidence: B)"
"5. The loading dose of clopidogrel for patients undergoing PCI after fibrinolytic therapy should be 300 mg within 24 hours and 600 mg more than 24 hours after receiving fibrinolytic therapy.[2][14] (Level of Evidence: C)"
"6. Patients should be counseled on the need for and risks of dual antiplatelet therapy (DAPT) before placement of intra-coronary stents, especially drug eluting stents (DES), and alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of dual antiplatelet therapy.[15] (Level of Evidence: C)"
"7. The duration of P2Y12 receptor inhibitor therapy after stent implantation should generally be as follows:
a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 receptor inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily [16],prasugrel 10 mg daily [4], and ticagrelor 90 mg twice daily.[5] (Level of Evidence: B)
b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding.[15][17][18] (Level of Evidence: B)
c. In patients receiving bare metal stent (BMS) for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).[15][19] (Level of Evidence: B)"
Class III (Harm)
"1. Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack.[4] (Level of Evidence: B)"
Class IIa
"1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses.[8][20][21][22][23] (Level of Evidence: B)"
"2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 receptor inhibitor therapy after stent implantation, earlier discontinuation (e.g.,less than 12 months) of P2Y12 receptor inhibitor therapy is reasonable. (Level of Evidence: C)"
Class IIb
"1. Continuation of dual antiplatelet therapy (DAPT) beyond 12 months may be considered in patients undergoing drug eluting stent (DES) implantation.[4][5] (Level of Evidence: C)"

Dual Antiplatelet Therapy Compliance and Stent Thrombosis (DO NOT EDIT) [6]

Class III (Harm)

"1. PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT) for the appropriate duration of treatment based on the type of stent implanted. [15][24][25][26](Level of Evidence: B)"

References

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