Antithrombotic treatment in primary percutaneous coronary intervention

ABSTRACT

Introduction

Despite a timely mechanical reperfusion with primary percutaneous coronary intervention (pPCI) patients presenting with ST-elevation myocardial infarction (STEMI) display an increased risk of adverse cardiovascular events. Several studies have demonstrated that guideline-directed antithrombotic therapy is effective to reduce this risk. However, there is still much to be accomplished to improve antithrombotic therapies in this clinical setting.

Areas covered

This paper reviews current data on antithrombotic therapy in STEMI patients undergoing pPCI.

Expert opinion

Antithrombotic therapy for STEMI patients undergoing pPCI should take into account the variability of thrombotic and bleeding risk in the short and long term. Patients with STEMI profit from the administration of early onset antiplatelet agents and anticoagulation to achieve sufficient and predictable antithrombotic effect at the time of pPCI. Thereafter, antithrombotic therapies should be tailored to individual risk of recurrence over the long term, to avoid excess bleeding, while ensuring adequate secondary ischemic prevention.

KEYWORDS:

• anticoagulation therapy
• aspirin
• clopidogrel
• coronary artery disease
• dual antiplatelet therapy
• ticagrelor
• percutaneous coronary intervention
• prasugrel

Article highlights

• In patients with STEMI undergoing pPCI the objective of antiplatelet agents and parenteral anticoagulation is to provide early onset inhibition of arterial thrombosis.

• UFH remains the standard anticoagulation in STEMI patients without excessive bleeding risk.

• A pre-treatment with antiplatelet agents is recommended, though the clinical benefit of pre-treatment remains to be demonstrated.

• A dual antiplatelet therapy consisting of aspirin with either prasugrel or ticagrelor should be administered as soon as possible in STEMI patients undergoing pPCI, unless contraindicated.

• Recent evidence suggests a superior anti-ischemic efficacy of prasugrel over ticagrelor for ACS patients managed invasively. However, the comparative antithrombotic efficacy of prasugrel and ticagrelor in STEMI patients receiving mechanical reperfusion warrants further investigation.

• Even in the era of more potent drugs, there is evidence of delayed onset of platelet inhibition with available oral therapies in the acute phase of STEMI.

• The use of crushed or chewed antiplatelet agents and the restriction or antagonism of opioids speed up the onset of antiplatelet action of oral P2Y₁₂-receptor inhibitors, without evidence for improved outcomes.

• De-escalation of antiplatelet treatment with or without platelet function or genotype guidance may be considered in selected STEMI cases presenting clinical conditions that impede to continue with conventional regimens.

• The optimal antithrombotic regimen in patients with an indication for lifelong OAC and in the elderly remains to be assessed, given the paucity of data available for these specific populations.

Declaration of interest

S Cassese received lecture fees from Astra Zeneca. The authors have 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.

Reviewer disclosures

A reviewer of this manuscript has disclosed that they receive lecture/advisory board fees by Astrazeneca, Chiesi. Peer reviewers in this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.