Antiplatelet therapy for coronary artery disease in 2023: current status and future prospects

ABSTRACT

Introduction

Antiplatelet therapy is the cornerstone for prevention and management of ischemic complications among patients with coronary artery disease. Over the past decades, advancement in stent technologies and increasing awareness about the prognostic impact of major bleeding have led to evolving priorities in the management of antithrombotic regimens, from exclusive concerns regarding recurrent ischemic events to an individualized equipoise between ischemic and bleeding risk through a patient-centered comprehensive approach.

Areas covered

The purpose of this review is to highlight the current evidence that supports the various management strategies for antiplatelet therapy and discuss future directions of pharmacological regimens for coronary syndromes. We will also discuss the rationale behind use of antiplatelet therapy, current guideline recommendations, risk scores for ischemic and bleeding risk evaluation, and tools to help assess treatment response.

Expert opinion

While tremendous advancements have been made in antithrombotic agents and regimens, future directions for antiplatelet therapy in patients with coronary artery disease would involve focus on novel therapeutic targets, development of new antiplatelet agents, implementation of more innovative regimens with current agents and further research to validate contemporary antiplatelet strategies.

KEYWORDS:

• Antiplatelet therapy
• aspirin
• bleeding
• dual antiplatelet therapy
• oral anticoagulation
• P2Y₁₂ inhibitor
• pharmacology
• thrombosis

Article highlights

• The role of antiplatelet therapy in patients with coronary artery disease includes both prevention of acute coronary occlusions in case of plaque erosion or rupture and regulation of atherosclerotic disease progression.

• Prescription of aspirin for primary prevention of atherosclerotic cardiovascular disease might be cautiously considered in patients at high or very high risk of cardiovascular events and without increased bleeding risk.

• While many scores and risk stratifying models provide a prognostic stratification and predict ischemic and bleeding events after PCI, physician judgment is crucial in guiding the choice of antiplatelet therapy as patient risks are dynamic and fluctuate over time.

• The choice of P2Y₁₂ inhibitor and duration of dual antiplatelet therapy are determined by clinical presentation and individual patient risk profile as well as special scenarios such as need for chronic oral anticoagulation.

• Strategies to reduce repeat ischemic events, particularly among patients considered to be at high thrombotic risk, include increasing the potency of P2Y₁₂ inhibition, prolonging the duration of dual antiplatelet therapy and dual-pathway inhibition.

• Bleeding risk may be reduced by shortening the duration of dual antiplatelet therapy, employing aspirin-free strategies and de-escalating antiplatelet regimens.

Declaration of interest

R Mehran reports institutional research grants from Abbott, Abiomed, Applied Therapeutics, Arena, AstraZeneca, Bayer, Biosensors, Boston Scientific, Bristol-Myers Squibb, CardiaWave, CellAegis, CERC, Chiesi, Concept Medical, CSL Behring, DSI, Insel Gruppe AG, Medtronic, Novartis Pharmaceuticals, OrbusNeich, Philips, Transverse Medical, Zoll; personal fees from ACC, Boston Scientific, California Institute for Regenerative Medicine (CIRM), Cine-Med Research, Janssen, WebMD, SCAI; consulting fees paid to the institution from Abbott, Abiomed, AM-Pharma, Alleviant Medical, Bayer, Beth Israel Deaconess, CardiaWave, CeloNova, Chiesi, Concept Medical, DSI, Duke University, Idorsia Pharmaceuticals, Medtronic, Novartis, Philips; Equity<1% in Applied Therapeutics, Elixir Medical, STEL CONTROLRAD (spouse); Scientific Advisory Board for AMA, Biosensors (spouse).

A Spirito received a research grant from the Swiss National Science Foundation (SNSF).

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

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

Additional information

Funding

This paper was not funded.