Personalized dual antiplatelet therapy in acute coronary syndromes: striking a balance between bleeding and thrombosis
Purpose of review: Dual antiplatelet therapy (DAPT)-aspirin in conjunction with a P2Y12 inhibitor-is the cornerstone of managing patients with acute coronary syndromes post-revascularization, but the clinical response is highly variable, with potentially devastating consequences. Herein, we review the mechanisms underpinning said variability and explore emerging approaches to normalizing therapeutic benefit.
Recent findings: The potent P2Y12 inhibitors, prasugrel and ticagrelor, exhibit minimal inter-individual variability, replacing clopidogrel in DAPT and achieving greater rates of therapeutic response. However, these benefits decline in later phases when bleeding risk begins to supersede that of ischemia. Guided de-escalation of P2Y12 inhibition as well as shortening DAPT duration have emerged as strategies that retain antithrombotic efficacy while reducing bleeding risk. Aspirin is the other component of DAPT but is also used in isolation for secondary prevention of thrombotic disease. In contrast to the P2Y12 inhibitors, genetic influences on aspirin non-response appear to be outweighed by a triad of clinical factors: non-adherence, enteric aspirin use, and inappropriate dosing according to bodyweight and BMI. Multiple de-escalation strategies for DAPT have been shown to mitigate bleeding risk, but it remains unclear which approach is ideal, necessitating head-to-head investigations to determine which exhibits the most favorable cost-to-benefit ratio. However, there is likely a role for more than one approach in clinical practice, depending on patient risk profile. Our approach to aspirin use is also in need of reassessment: strategies to improve adherence, avoidance of enteric aspirin in cardiac patients, and dose adjustment according to bodyweight and/or BMI are all likely to improve rates of therapeutic response. Moreover, platelet function testing may have a role in identifying patients expected to benefit from primary prophylactic aspirin.
Funding
Open Access funding provided by the IReL Consortium.
History
Comments
The original article is available at https://link.springer.com/Published Citation
Shpigelman J, Proshkina A, Daly MJ, Cox D. Personalized dual antiplatelet therapy in acute coronary syndromes: striking a balance between bleeding and thrombosis. Curr Cardiol Rep. 2023;25(7):693-710Publication Date
1 June 2023External DOI
PubMed ID
37261665Department/Unit
- Medicine
- School of Pharmacy and Biomolecular Sciences
- Undergraduate Research
- School of Medicine
Publisher
SpringerVersion
- Published Version (Version of Record)