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Antiplatelet therapy: is it time for an individualised approach?

ESC Congress 2010

Acute Coronary Syndromes (ACS)

The variability of platelet inhibition, the role of testing platelet response as well as genetic profiling and the risk of bleeding and drug interactions are heavily debated issues which were discussed in a very well attended clinical seminar.

Prof. Gawaz from Tuebingen, DE, gave a summary on the current evidence of platelet response testing by concluding that it is not ready for clinical use yet: these tests are not standardized and no randomized trials exist to support the posit that test results will lead to a reduction in clinical events by inducing any change in therapy – either an increase in the dose of clopidogrel or a switch to other more potent and reliable agents.

Prof. De Servi from Pavia, IT, discussed the important issue of bleeding as an independent risk factor for worse clinical outcome after PCI in patients with ACS. Recent studies have shown different bleeding risks with newer antiplatelet agents such as prasugrel and ticagrelor. There seems to be a trade-off between increased bleeding risk, which needs to be balanced against greater and more consistent platelet inhibition with these new drugs.

Dr. Simon from Paris, FR, discussed the influence of concomitant proton-pump inhibitor-therapy on antiplatelet effects of clopidogrel, which share the cytochrome P450 pathway for metabolisation and showed that existing evidence does prove that bleeding risk from gastro-duodenal ulcers can be substantially reduced with PPIs. One RCT, COGENT, which is unpublished, however, reported a 45% decrease in bleeding risk in ACS patients treated with omeprazole, while cardiovascular events did not increase compared to the placebo group.

Finally, Prof. Montalescot from Paris spoke on the role of genetic profiling in guiding antiplatelet therapy. Several point-of-care genotype tests are now available that can assess the loss-of function-allele CYP2C19 in few hours. This allele has been shown to be associated with impaired platelet inhibition response to clopidogrel and with an increase in adverse clinical events. However, Dr. Montalescot concluded by saying that studies are lacking to prove the clinical utility of genetic profiling in guiding antiplatelet therapy or to show complementary or superior value of genetic over platelet response testing. Ongoing randomized trials will show whether genetic testing may improve the choice of therapy especially in high risk patients for either stent thrombosis or bleeding.




Antiplatelet therapy: is it time for an individualised approach?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.