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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Mr Carlo Patrono,
This session looked at the application of antiplatelet therapy across a broad range of indications.
Christoph Bode reviewed the trials assessing the use of aspirin as primary prevention of cardiovascular disease and emphasised the lack of benefit of aspirin for reducing cardiovascular mortality as well as an apparent gender difference in the efficacy of aspirin in preventing myocardial infarction and stroke, although this gender difference is not supported by a recent Antithrombotic Trialists Collaboration analysis. Dual antiplatelet therapy with aspirin and clopidogrel also did not appear more effective than aspirin alone in a primary prevention setting when assessed in the CHARISMA study. Finally, the role of antiplatelet therapy in the prevention of cardioembolic complications of atrial fibrillation was reviewed and the limitation of this approach relative to warfarin or newer agents was emphasised.
Gilles Montalescot presented an overview of the use of antiplatelet agents, also with regard to some adjunctive anticoagulant treatments, in the management of acute coronary syndromes. There is a consistency of benefit with more effective P2Y12 inhibition with a range of new strategies, albeit at the expense of higher rates of non-CABG-related major bleeding, although double-dose clopidogrel compared to a standard regimen failed to achieve a significant reduction in the primary endpoint in CURRENT OASIS 7. Trends were noted towards reduced mortality with prasugrel and ticagrelor in patients with ST-elevation myocardial infarction managed with primary percutaneous coronary intervention without evidence of a bleeding penalty in this subgroup whereas more research is required in patients with STEMI managed initially with fibrinolytic therapy. Although upstream use of GP IIb/IIIa inhibitors has not demonstrated benefit in patients with non-ST-elevation ACS, there is a possibility still that certain subgroups of STEMI patients might benefit from more intensive treatment prior to reaching the catheterization laboratory and more work is ongoing to assess this.
Dominick Angiolillo developed the theme of the session by focussing on the use of antiplatelet therapy in those undergoing coronary stenting both in the context of ACS and for the management of stable CAD. Low aspirin maintenance dose (75-100mg daily) is supported by current data. There has been progressive improvement in the safety and efficacy of P2Y12 inhibitors which has narrowed the indications for GP IIb/IIIa antagonists. Evidence supporting the use of bivalirudin in patients with high bleeding risk as an alternative to GP IIb/IIIa antagonists was also presented. The efficacy and safety of prasugrel and ticagrelor appear similar although ticagrelor has more compelling mortality data but only a head-to-head trial between these agents will answer important questions about their comparative properties.
Pierre Amarenco reviewed the use of antiplatelet drugs in the acute setting of an ischaemic stroke and in secondary prevention. In contrast to the treatment of acute MI, treatment options are extremely limited in acute stroke, with only 5% of patients being eligible for thrombolysis and the vast majority being treated with aspirin only. In the secondary prevention of stroke, both clopidogrel and aspirin combined with dipyridamole are somewhat more effective than aspirin alone but the latter is also considered an acceptable treatment option in both European and North American guidelines. The choice between clopidogrel and aspirin plus dipyridamole may be guided by considerations of tolerability and safety favouring clopidogrel over the combination. The role of dual antiplatelet therapy with aspirin and clopidogrel is uncertain and Prof. Amarenco emphasised the importance of early recruitment of patients after the acute event to trials of novel antithrombotic strategies, with particular consideration of the aetiology of the stroke and selection of patients with stroke of atherothrombotic origin, an approach that is being tested in ongoing trials.
Antiplatelet therapy: how, why, when
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