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Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines
Affiliations- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
- Clinic of Cardiac and Vascular diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
- Department of Theoretical Foundations of Bio-Medical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Ravenna, Italy
- IIIrd Department of Cardiology, Silesian Center for Heart Diseases, Faculty of Medicine in Zabrze, Medical University of Silesia, Zabrze, Poland
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Hospital of the Internal Affairs and Administration Ministry, Warsaw, Poland
- Postgraduate Medicine, University of Hertfordshire, United Kingdom and Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Cardiology, Poznan University of Medical Sciences
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
- Ist Department of Cardiology, Medical University of Gdańsk, Poland
- Ist Department of Cardiology, Medical University of Gdańsk, Poland
- Department of Medical Sciences and Uppsala Clinical research center, Uppsala University Hospital, Uppsala, Sweden
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
- Ist Department and Chair of Cardiology, Medical University of Lodz Bieganski Hospital, Lodz Poland
- University of Information Technology and Management in Rzeszow, Poland
- Department of Cardiology The Pope John Paul II Hospital in Zamosc, Poland
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Chair and Department of Cardiology, Wroclaw Medical University
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Poland
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland
- Department of Cardiology, Medical University of Vienna, Austria
- Department of Emergency Medical Service, Strategic Planning University of Dabrowa Gornicza, Dabrowa Gornicza, Poland
- Faculty of Medicine, Katowice School of Technology, Katowice, Katowice, Poland
- Department of Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy
- Pavia, Italy
- Departement of Intensive Cardiac Therapy, National Institute of Cardiology, Warsaw, Poland
- Department of Cardiology, Medical University of Bialystok, Poland
- Division of Cardiology, Ospedale degli Infermi ASL Biella, Università del Piemonte Orientale, Italy
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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Abstract
The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the dual antiplatelet therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in postacute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic treatment (DATT) appear after a longer time from ACS (more than two years) and/or from cessation of DAPT (more than one year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.
Abstract
The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the dual antiplatelet therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in postacute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic treatment (DATT) appear after a longer time from ACS (more than two years) and/or from cessation of DAPT (more than one year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.
Keywords
prolonged antithrombotic therapy, chronic coronary syndrome, acute coronary syndrome, rivaroxaban, ticagrelor, clopidogrel, prasugrel
About this articleTitle
Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines
Journal
Issue
Article type
Review article
Pages
177-190
Published online
2020-09-30
Page views
1190
Article views/downloads
927
DOI
Bibliographic record
Medical Research Journal 2020;5(3):177-190.
Keywords
prolonged antithrombotic therapy
chronic coronary syndrome
acute coronary syndrome
rivaroxaban
ticagrelor
clopidogrel
prasugrel
Authors
Jacek Kubica
Piotr Adamski
Piotr Niezgoda
Dimitrios Alexopoulos
Jolita Badarienė
Andrzej Budaj
Katarzyna Buszko
Dariusz Dudek
Tomasz Fabiszak
Mariusz Gąsior
Robert Gil
Diana A. Gorog
Stefan Grajek
Paul A. Gurbel
Marcin Gruchała
Miłosz J. Jaguszewski
Stefan James
Young-Hoon Jeong
Bernd Jilma
Jarosław D. Kasprzak
Andrzej Kleinrok
Aldona Kubica
Wiktor Kuliczkowski
Jacek Legutko
Maciej Lesiak
Jolanta M. Siller-Matula
Klaudiusz Nadolny
Krzysztof Pstrągowski
Salvatore Di Somma
Giuseppe Specchia
Janina Stępińska
Udaya S. Tantry
Agnieszka Tycińska
Monica Verdoia
Wojciech Wojakowski
Eliano P. Navarese
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