Genotype-guided dual antiplatelet therapy in cerebrovascular disease: assessing the risk and benefits for ethnic populations

ABSTRACT

Introduction

Cerebrovascular disease is a leading cause of morbidity and mortality in the world and antiplatelet therapy is a main pharmacologic means of secondary prevention. Clinical information has accumulated about benefit of dual antiplatelet therapy in certain clinical scenarios, genetic causes of antiplatelet resistance and its effect on clinical outcomes, and ethnic and geographic distributions of genetic polymorphisms.

Areas Covered

This review covers literature related to the pharmacogenomics of antiplatelet agents with a focus on ethnic variability, antiplatelet resistance, and dual antiplatelet therapy in cerebrovascular disease.

Expert Opinion

Selecting patients for dual antiplatelet therapy and specific agents require consideration of multiple factors. Ethnic factors should be considered in certain circumstances, but additional research is needed to determine the generalizability of the findings.

KEYWORDS:

• stroke
• antiplatelet therapy
• dual antiplatelet therapy
• genetics
• ethnicity

Article highlights

• Antiplatelets are a mainstay of the secondary prevention of ischemic stroke with randomized controlled trials showing the effectiveness of dual aniplatelet therapy in select clinical scenarios.

• The use of antiplatelet agents is complicated by antiplatelet resistance, a complex phenomenon, which can in part be due factors related to genotype.

• Genotype-related antiplatelet resistance is best studied with loss of function and gain of function polymorphisms of CYP2C19 that alter clopidogrel response and there is considerable ethnic variability in allelic frequency.

• Emerging evidence suggests that in certain ethnic populations, a genotype-guided approach to strategy may improve stroke prevention outcomes. Stroke prevention guidelines acknowledge this area requires further clarification.

• Lastly, there is emerging evidence for a role in measuring antiplatelet resistance in the carotid stenting arena for symptomatic extracranial carotid stenosis.

Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.