Antiplatelet Therapy in Acute Coronary Syndrome (ACS) and PCI: Practical Strategies to Improve Outcomes.

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Antiplatelet Therapy in Acute Coronary Syndrome (ACS) and PCI: Practical Strategies to Improve Outcomes.

Am J Cardiol. 2010 Nov 1;106(9):S2-3

Authors: Angiolillo DJ, Bhatt DL, Montalescot G, Wiviott SD

Antiplatelet therapy is essential to reduce the risk for ischemic events in patients with acute coronary syndromes (ACS). A fundamental issue in prescribing antiplatelet therapy remains balancing an increased risk for bleeding with efficacy in thrombosis prevention, emphasizing the need to individualize ACS treatment. The current standard is the combination of aspirin with clopidogrel and/or a glycoprotein IIb/IIIa inhibitor. However, evidence indicates reduced platelet inhibition with clopidogrel in carriers of certain genotypes of cytochrome P450 2C19, and American and European regulators recently issued warnings concerning the concomitant use of clopidogrel with drugs that inhibit cytochrome P450 2C19, such as the proton pump inhibitor omeprazole. Clinical trial data illustrate that more potent inhibition of platelets with prasugrel, the newest thienopyridine with a different metabolic pathway from that of clopidogrel, or ticagrelor, a nonthienopyridine, results in faster onset of action and more predictable responses and provides improved efficacy. This increased potency, however, is accompanied by an increased risk for bleeding. Outcomes with antiplatelet therapy also can differ on the basis of patient factors, including co-morbid diabetes mellitus, chronic kidney disease, and patient age. The optimal timing and dosing of antiplatelet therapy in patients who undergo percutaneous intervention has not been fully determined, and questions remain concerning which patients with unstable angina or non-ST elevation myocardial infarction are candidates for early invasive treatment. Clinicians, therefore, should understand the importance of tailoring antithrombotic regimens to individual patients to optimize treatment safety and efficacy. Online Access: This CME Multimedia Activity is also available through the Web site of The American Journal of Cardiology ( Click on the Multimedia tab at the top of the page and then select "CME Multimedia Activities" to access this program through the Journal Homepage.

PMID: 21029811 [PubMed - in process]

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