Oral anticoagulant use in addition to antiplatelet therapy for secondary prevention in acute coronary syndrome: current perspectives

Abstract

Patients with acute coronary syndrome (ACS) are typically managed with long-term dual antiplatelet therapy of acetylsalicylic acid plus a P2Y₁₂ platelet receptor antagonist; however, although effective, the risk of another vascular event within 12 months remains at approximately 10%. Considerable efforts have been made to find improved therapeutic approaches to secondary prevention in ACS. The ATLAS ACS 2-TIMI 51 trial demonstrated that rivaroxaban (2.5 mg twice daily) significantly reduced recurrent vascular events, increased the risk of major bleeding but not the risk of fatal bleeding, and resulted in reduced rates of death from cardiovascular causes. These results formed the basis for approval in Europe of rivaroxaban (2.5 mg twice daily) in conjunction with standard antiplatelet therapy for the secondary prevention of ACS.

Keywords::

• acute coronary syndrome
• apixaban
• clopidogrel
• dabigatran
• prasugrel
• rivaroxaban
• ticagrelor
• vorapaxar
• warfarin

Financial & competing interests disclosure

The author would like to thank Abigail Macleod, who provided writing support with funding from Bayer HealthCare Pharmaceuticals and Janssen Scientific Affairs, LLC, who sponsored/funded the manuscript in whole or in part. AGG Turpie has worked as a consultant to Bayer Pharma, Astellas, Portola and Takeda. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Antiplatelet therapy (with acetylsalicylic acid [ASA] alone or with ASA plus clopidogrel) has been shown to improve the prognosis of patients with acute coronary syndrome (ACS).

• Despite long-term dual antiplatelet therapy, patients with ACS have an approximately 10% risk of another ischemic event within 12 months post-index ACS event.

• There is a need for improved therapeutic options to reduce the risk of patients experiencing secondary events.

• The vitamin K antagonists (VKAs), targeting the coagulation cascade, both alone or in combination with ASA, demonstrated a significant benefit in reducing ischemic risk compared with ASA alone. However, the VKAs increased bleeding risk and have several limitations to their use.

• The non-VKA oral anticoagulants (NOACs) overcome several limitations of warfarin but require careful risk assessment and monitoring through regular follow-up; their respective efficacy and safety outcomes have been evaluated in Phase II and Phase III trials.

• Of the NOACs, only rivaroxaban in combination with standard antiplatelet therapy (ASA plus clopidogrel or ticlopidine) has shown clinical benefit to date.

• Further studies are required to establish the safety of this approach with other, more potent antiplatelet/oral anticoagulant combinations.

Notes