Assessing platelet reactivity after drug eluting stent implantation: state of the art

ABSTRACT

Introduction: Platelets play a pivotal role in the occurrence of recurrent ischemic events in coronary artery disease patients who are treated with drug-eluting stents and are on dual antiplatelet therapy (DAPT).

Areas covered: High platelet reactivity (HPR) to adenosine diphosphate during clopidogrel therapy is a strong predictor of post-stenting ischemic event occurrences. However, uniform use of potent P2Y₁₂ receptors blockers to overcome HPR is associated with elevated bleeding risk. Selective de-escalation of P2Y₁₂ receptor blocker therapy based on PFT in patients with acute coronary syndrome treated with stenting has been shown to be associated with a similar risk of ischemic event occurrence but with a reduced risk of bleeding. This review aims to discuss the role of PFT in guiding DAPT in patients treated with DES. We searched electronic databases from January 2000 to December 2019 for literatures evaluating the role of platelet function assessment after drug eluting stents.

Expert opinion: Platelet function guided therapy improves patient outcomes by lessening bleeding and limiting the overuse of highly potent P2Y₁₂ inhibitors. Interest in this area of de-escalation of therapy will likely grow as the consequences of bleeding are better recognized and the cost of healthcare gains greater focus.

KEYWORDS:

• Platelets
• P2Y₁₂ receptor blocker
• platelet function testing
• drug eluting stenting
• coronary artery disease
• acute coronary syndrome
• stent thrombosis
• bleeding

Article highlights

• Platelets play a pivotal role in the occurrence of recurrent ischemic events during dual antiplatelet therapy (DAPT) in coronary artery disease patients treated with drug-eluting stents.

• High platelet reactivity to ADP in patients treated with clopidogrel, the most widely used P2Y₁₂ receptor blocker, is associated with an increased risk for post-stenting ischemic event occurrences.

• Uniform use of potent P2Y₁₂ receptor blockers such as prasugrel and ticagrelor to overcome HPR, is associated with an increased risk for bleeding during long-term therapy.

• Randomized trials fail to demonstrate the utility of platelet function tenting (PFT), but are associated with serious limitations.

• Excessive bleeding may be reduced and net clinical outcome improved by utilizing serial PFT in patients selectively treated with the more potent P2Y₁₂ receptor blockers as shown in the TROPICAL-ACS study.

Declaration of interest

P Gurbel is a consultant and/or receives honoraria from Bayer, Merck, Janssen, Medicure and USWorld Meds. P Gurbel has also received grants from the NIH, Janssen, Merck, Bayer, Haemonetics, Instrumentation Labs and Amgen. P Gurbel is also holding stock or stock options in Merck, Medronic and Pfizer and holding patents in the area of personalized antiplatelet therapy and interventional cardiology. U Tantry receives honoraria from UpToDate. 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.