Antiplatelet strategies in elderly people: still a long way to go

Abstract

Outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention have been significantly improved with the potent P2Y12 receptor inhibitors prasugrel and ticagrelor. 1 Wiviott SD Braunwald E McCabe CH et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007; 357: 2001-2015 Crossref PubMed Scopus (5562) Google Scholar , 2 Wallentin L Becker RC Budaj A et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361: 1045-1057 Crossref PubMed Scopus (5545) Google Scholar Elderly patients comprise a growing subset of the acute coronary syndrome population. This subset is characterised by multiple organ changes and various comorbidities, which altogether culminate in an increased risk of both ischaemic and bleeding complications after percutaneous coronary intervention. Platelet function testing has been established and validated to predict ischaemic and bleeding events in patients treated with percutaneous coronary intervention. 3 Aradi D Kirtane A Bonello L et al. Bleeding and stent thrombosis on P2Y12-inhibitors: collaborative analysis on the role of platelet reactivity for risk stratification after percutaneous coronary intervention. Eur Heart J. 2015; 36: 1762-1771 Crossref PubMed Scopus (268) Google Scholar , 4 Tantry US Bonello L Aradi D et al. Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol. 2013; 62: 2261-2273 Summary Full Text Full Text PDF PubMed Scopus (756) Google Scholar However, previous studies, 5 Collet JP Cuisset T Range G et al. Bedside monitoring to adjust antiplatelet therapy for coronary stenting. N Engl J Med. 2012; 367: 2100-2109 Crossref PubMed Scopus (759) Google Scholar , 6 Aradi D Storey RF Komocsi A et al. Expert position paper on the role of platelet function testing in patients undergoing percutaneous coronary intervention. Eur Heart J. 2014; 35: 209-215 Crossref PubMed Scopus (213) Google Scholar enrolling mostly low-risk patients with little use of potent antiplatelet drugs, have been unable to show clinical superiority of strategies that implemented platelet function testing for treatment guidance. Nevertheless, elderly patients undergoing percutaneous coronary intervention represent a high-risk cohort that might derive clinical benefit from platelet function testing to monitor and adjust the level of platelet inhibition. Platelet function monitoring to adjust antiplatelet therapy in elderly patients stented for an acute coronary syndrome (ANTARCTIC): an open-label, blinded-endpoint, randomised controlled superiority trialPlatelet function monitoring with treatment adjustment did not improve the clinical outcome of elderly patients treated with coronary stenting for an acute coronary syndrome. Platelet function testing is still being used in many centres and international guidelines still recommend platelet function testing in high-risk situations. Our study does not support this practice or these recommendations. Full-Text PDF