Antiplatelet and anticoagulation agents in acute coronary syndromes: What is the current status and what does the future hold?

• Published in: The American heart journal Vol. 168; no. 5; pp. 611 - 621
• Main Authors: Huber, Kurt, MD, Bates, Eric R., MD, Valgimigli, Marco, MD, PhD, Wallentin, Lars, MD, PhD, Kristensen, Steen Dalby, MD, DMSc, Anderson, Jeffrey L., MD, Lopez Sendon, Jose Luis, MD, Tubaro, Marco, MD, Granger, Christopher B., MD, Bode, Christoph, MD, Ohman, Erik Magnus, MD, Steg, Philippe Gabriel, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2014; Elsevier Limited
• Subjects: Acute Coronary Syndrome - drug therapy; Acute coronary syndromes; Adenosine - analogs & derivatives; Adenosine - therapeutic use; Adenosine Monophosphate - analogs & derivatives; Adenosine Monophosphate - therapeutic use; Anticoagulants - therapeutic use; Aspirin - therapeutic use; Cardiovascular; Clinical outcomes; Drug therapy; Drug Therapy, Combination; Enoxaparin - therapeutic use; Heart attacks; Heparin - therapeutic use; Hirudins; Humans; Lactones - therapeutic use; Mortality; Peptide Fragments - therapeutic use; Peptides - therapeutic use; Piperazines - therapeutic use; Platelet Aggregation Inhibitors - therapeutic use; Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors; Polysaccharides - therapeutic use; Prasugrel Hydrochloride; Purinergic P2Y Receptor Antagonists - therapeutic use; Pyridines - therapeutic use; Receptors, Thrombin - antagonists & inhibitors; Recombinant Proteins - therapeutic use; Thiophenes - therapeutic use; Tyrosine - analogs & derivatives; Tyrosine - therapeutic use; Warfarin - therapeutic use
• ISSN: 0002-8703; 1097-6744; 1097-6744
• DOI: 10.1016/j.ahj.2014.06.014

Mortality and morbidity in acute coronary syndromes (ACSs), caused principally by plaque erosion or rupture leading to thrombus formation and myocardial ischemia, have been reduced by a combination of antithrombotic agents (antiplatelet drugs and anticoagulants) and early revascularization. Aspirin is the foundation antiplatelet agent. New P2Y12 receptor inhibitors (prasugrel and ticagrelor) have clear benefits compared with clopidogrel for dual antiplatelet therapy, and cangrelor or vorapaxar, a thrombin receptor inhibitor, may be of value in specific settings. Anticoagulation uses 1 of 4 choices: bivalirudin, unfractionated heparin, enoxaparin, and fondaparinux. Moreover, some patients (such as those who have chronic atrial fibrillation) require triple therapy with aspirin, clopidogrel, plus an anticoagulant, frequently a vitamin K antagonist. New oral anticoagulants have been shown to be at least as effective as vitamin K antagonists in atrial fibrillation and led to fewer bleeding complications. Finally, the combination of aspirin, clopidogrel, and low-dose rivaroxaban has recently been approved by the European Medicines Agency (but not the Food and Drug Administration) for secondary prevention after ACS. Several strategies have been developed to balance the potential benefit of antithrombotic therapy against the risk of bleeding complications, for example, radial access in coronary angiography or restricted use of combination therapy, and others are under investigation, such as discontinuation of aspirin. This overview summarizes the current status of antithrombotic therapy in ACS and describes strategies currently explored to optimize its benefit/risk ratio.