Abstract

BackgroundIn patients with acute coronary syndrome (ACS), angiotensin-converting enzyme (ACE) inhibitors are preferred over angiotensin receptor blockers (ARBs). However, in a recent pilot study, treatment with ACE inhibitors was associated with increased platelet reactivity compared to ARBs. Therefore, we sought to investigate the impact of renin-angiotensin-aldosterone system (RAAS) blockade with ACE inhibitors and ARBs on platelet aggregation in patients with ACS undergoing percutaneous coronary intervention.MethodsOn-treatment residual platelet reactivity in response to arachidonic acid (AA), adenosine diphosphate (ADP), SFLLRN, AYPGKF, and collagen was assessed by multiple electrode aggregometry (MEA) in 197 ACS patients on dual antiplatelet therapy (DAPT) with aspirin and either prasugrel or ticagrelor.ResultsOne hundred sixty-five (83.7%) patients were treated with ACE inhibitors, 32 (16.3%) with ARBs. On-treatment residual AA- and ADP-inducible platelet reactivity was significantly higher in patients with ACE inhibitors (both p < 0.05). Likewise, SFLLRN was significantly higher in patients with ACE inhibitors (p = 0.036) and there was a trend for higher AYPGKF- and collagen-inducible platelet reactivity (p = 0.053 and p = 0.082). The incidence of high on-treatment residual platelet reactivity AA was significantly higher in patients with ACE inhibitors (52 [31.5%] vs. 3 [9.4%] patients; p = 0.019).ConclusionACE inhibitors are associated with increased on-treatment residual platelet reactivity in ACS patients with potent DAPT. Further clinical trials are needed to elucidate the role of RAAS blockade with ACE inhibitors and ARBs in ACS patients treated according to current standards.

Highlights

  • Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the antithrombotic standard regimen for patients presenting with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) [1,2,3]

  • On-treatment residual arachidonic acid (AA)- and adenosine diphosphate (ADP)-inducible platelet reactivity was significantly higher in patients with angiotensin-converting enzyme (ACE) inhibitors as compared to patients with angiotensin receptor blockers (ARBs) (AA: 17 aggregation units (AU) [12,13,14,15,16,17,18,19,20,21,22] vs. 13 AU [7,8,9,10,11,12,13,14,15,16,17,18], p = 0.006; ADP: 20 AU (16–24) vs. 16 AU (11–20), p < 0.001; Table 2, Fig. 1)

  • SFLLRNinducible platelet reactivity was significantly higher in ARB N = 32

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Summary

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the antithrombotic standard regimen for patients presenting with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) [1,2,3]. Methods On-treatment residual platelet reactivity in response to arachidonic acid (AA), adenosine diphosphate (ADP), SFLLRN, AYPGKF, and collagen was assessed by multiple electrode aggregometry (MEA) in 197 ACS patients on dual antiplatelet therapy (DAPT) with aspirin and either prasugrel or ticagrelor. Results One hundred sixty-five (83.7%) patients were treated with ACE inhibitors, 32 (16.3%) with ARBs. On-treatment residual AA- and ADP-inducible platelet reactivity was significantly higher in patients with ACE inhibitors (both p < 0.05). Further clinical trials are needed to elucidate the role of RAAS blockade with ACE inhibitors and ARBs in ACS patients treated according to current standards

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