New directions for pharmacotherapy in the treatment of acute coronary syndrome

ABSTRACT

Introduction: Acute coronary syndromes (ACS) are one of the leading causes of death worldwide. Several landmark trials, followed by a widespread introduction of new agents, have significantly improved ACS outcomes in recent years. However, despite the use of contemporary therapy, a substantial number of ACS patients continue to suffer from cardiovascular events.

Areas covered: The aim of this review was to summarize available data on innovative drugs and pharmacological strategies that have potential to amend the current ACS therapy. We present the results of recent large clinical trials, as well as insights from ongoing phase III and phase IV studies, exploring the value of new strategies for the improvement of outcomes in ACS.

Expert opinion: More potent platelet inhibition, more profound lipid reduction and possibly anti-inflammatory action are considered to have potential to further reduce the rates of adverse cardiovascular and thrombotic events in ACS patients. ‘Hit fast, hit hard’ approach regarding novel antiplatelet and lipid-lowering therapy seems attractive, but it has to be considered that these strategies may be associated with increased adverse events rate. Introduction of cangrelor and ezetimibe, and potentially future recognition of proprotein convertase subtilisin/kexin type 9 antibodies, are likely to alter the landscape of ACS pharmacotherapy.

KEYWORDS:

• Acute coronary syndrome
• cangrelor
• CETP inhibitors
• ezetimibe
• losmapimod
• myocardial infarction
• P2Y12 receptor inhibitor pre-treatment
• pain management
• PCSK-9 antibodies

Article highlights

• Despite the widespread use of innovative therapy, a substantial number of ACS patients continue to suffer from cardiovascular events.

• Currently the ACS-related research appears to focus mainly on issues related to the three principal elements of ACS pathophysiology - immoderate platelet activation, plasma lipid control and inflammation.

• Currently available data do not support the use of pre-treatment with oral P2Y12 receptor inhibitors in patients with ACS, while cangrelor, this first commercially available intravenous P2Y12 receptor inhibitor, may prove to be useful in certain subsets of ACS patients.

• In some patients, even the highest tolerated statin dose may be insufficient to reach treatment goals or side effects may contribute to discontinuation of statin therapy. The only combined treatment with statin that has evidence of clinical benefit, is that with ezetimibe.

• Morphine, used as analgesic in ACS patients, shows a drug-drug interaction with oral P2Y12 receptor inhibitors, however clinical significance of this interplay remains unknown.

• ‘Hit fast, hit hard’ approach regarding both antiplatelet and novel lipid-lowering therapy seems attractive, but it has to be considered that these strategies may be associated with increased adverse events rate.

This box summarizes key points contained in the article.

Declaration of interest

M Koziński received honoraria for lectures from AstraZeneca. J Kubica received a consulting fee from AstraZeneca. 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.

Additional information

Funding

This paper was not funded.