Current antiplatelet options for NSTE-ACS patients

• Published in: QJM : An International Journal of Medicine 2012-10, Vol.105 (10), p.935-948
• Main Authors: CAYLA, G, SILVAIN, J, O'CONNOR, S. A, COLLET, J.-P, MONTALESCOT, G
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - diagnosis; Acute Coronary Syndrome - drug therapy; Acute Coronary Syndrome - metabolism; Acute Coronary Syndrome - physiopathology; Adenosine - agonists; Adenosine - analogs & derivatives; Adenosine - metabolism; Adenosine - pharmacology; Aspirin - pharmacology; Biological and medical sciences; Biological Availability; Comparative Effectiveness Research; Drug Monitoring - methods; Drug Synergism; Drug Therapy, Combination - methods; Electrocardiography; General aspects; Humans; Medical sciences; Pharmacovigilance; Piperazines - pharmacology; Platelet Activation - drug effects; Platelet Aggregation Inhibitors - pharmacology; Prasugrel Hydrochloride; Randomized Controlled Trials as Topic; Receptors, Purinergic P2Y - metabolism; Risk Assessment; Thiophenes - pharmacology; Ticlopidine - analogs & derivatives; Ticlopidine - pharmacology; Treatment Outcome
• ISSN: 1460-2725; 1460-2393
• DOI: 10.1093/qjmed/hcs077

Non-ST elevation (NSTE) myocardial infarction and unstable angina are the most common clinical presentations of acute coronary syndrome (ACS). Platelet activation is central to the pathogenesis of NSTE-ACS and consensus guidelines that advocate early revascularization supported by intensive antiplatelet therapy. This review examines the drugs used concurrently with aspirin as dual antiplatelet therapy in the NSTE-ACS setting. Clopidogrel represented an important therapeutic advance. However, variations in platelet response and a relatively slow onset of action compromise outcomes with clopidogrel. Evidence reviewed in this article shows that in NSTE-ACS patients, ticagrelor and prasugrel are more effective than clopidogrel and are relatively well tolerated, with an acceptable and manageable bleeding risk. The literature suggests several differences between ticagrelor and prasugrel that should allow clinicians to better tailor treatment to the patient. Head-to-head comparisons are now needed to compare directly the risks and benefits of ticagrelor and prasugrel in NSTE-ACS. Further studies also need to address other outstanding issues such as the benefits and risks of prasugrel pre-treatment and to stratify efficacy and tolerability according to diabetes mellitus (DM) and other co-morbidities. In the meantime, the issues discussed in this review should enhance clinicians' ability to optimize and individualize NSTE-ACS treatment, thereby further reducing the morbidity and mortality associated with this common cardiovascular condition.