Safety and efficacy of P2Y₁₂ inhibitor monotherapy in patients undergoing percutaneous coronary interventions

ABSTRACT

Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI.

Areas covered: P2Y₁₂ inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y₁₂ inhibitor monotherapy in patients undergoing PCI in different clinical settings.

Expert opinion: P2Y₁₂ inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y₁₂ monotherapy regimen warrant further investigation.

KEYWORDS:

• Antiplatelet therapy
• bleeding
• thrombosis
• percutaneous coronary intervention
• P2y₁₂ inhibitors
• aspirin
• atrial fibrillation

Article highlights

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor is a key strategy for the treatment and prevention of arterial thrombotic events in patients undergoing percutaneous coronary intervention (PCI).

• Since bleeding complications increase with DAPT duration, the use of P2Y₁₂ inhibitor monotherapy after a short course of DAPT might mitigate such risk while maintaining efficacy.

• A number of studies in different clinical scenarios of patients undergoing PCI have shown P2Y₁₂ inhibitor monotherapy after a short period of DAPT to provide a favorable safety profile compared to prolonged DAPT without compromising efficacy.

• Several unanswered questions regarding the ideal patient and the precise P2Y₁₂ monotherapy regimen warrant further investigation.

This box summarizes key points contained in the article.

List of abbreviations

ACS: acute coronary syndrome; CCS: chronic coronary syndrome; PCI: percutaneous coronary intervention; RCT: randomized controlled trial; DAPT: dual antiplatelet therapy; MI: myocardial infarction; DES: drug eluting stent; BARC: Bleeding Academic Research Consortium; TIMI: Thrombolysis In Myocardial Infarction; STE-ACS: ST-segment elevation acute coronary syndrome; NSTE-ACS: non-ST-segment elevation acute coronary syndrome; OAC: oral anticoagulant; TAT: triple antithrombotic therapy; DAT: dual antithrombotic therapy; VKA: vitamin K antagonist; DOAC: direct oral anticoagulant

Reviewer disclosures

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

Declaration of interest

D Capodanno declares that he has received consulting and speaker’s fee from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, outside the present work. F Andreotti declares that he has received consulting and speaker fees from Amgen, Bayer, B-I, BMS-Pfizer and Daiichi Sankyo, outside the present work. F Crea declares that he has received consulting and speaker’s fees from Biotronic, Amgen, Astra Zeneca, Servier, Menarini, BMS, outside the present work. DJ Angiolillo declares that he has received consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company and has received payments for participation in review activities from CeloNova and St Jude Medical, outside the present work. DJ Angiolillo also declares that his institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, Osprey Medical, Renal Guard Solutions and Scott R. MacKenzie Foundation. 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This paper was not funded.