Abstract
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.
Highlights
Dual antiplatelet therapy (DAPT), namely the combination of aspirin and a P2Y12 inhibitor, has become a standard antithrombotic regimen after stent implantation in patients who undergo percutaneous coronary intervention (PCI)
In a Korean nationwide registry-based study of patients with acute myocardial infarction (AMI) (KAMIR-NIH), Kang et al [43] reported that the use of potent P2Y12 inhibitors such as standard-dose prasugrel (HR: 2.14; 95% CI: 1.53–2.99; p < 0.001) and ticagrelor (HR: 2.26; 95% CI: 1.73–2.95; p < 0.001) was significantly associated with a higher bleeding risk than clopidogrel during a one-year follow-up after the index PCI for the acute coronary syndrome (ACS) events, there was no significant difference in the one-year composite ischemic outcomes among the three different antiplatelet regimens
With respect to the duration of DAPT, previous studies have shown a low risk of ischemic events and a high risk of bleeding events in East Asian patients who underwent PCI, and a short DAPT duration should be recommended even in patients with ACS who have a high risk of ischemic events [11,52,53]
Summary
Dual antiplatelet therapy (DAPT), namely the combination of aspirin and a P2Y12 inhibitor, has become a standard antithrombotic regimen after stent implantation in patients who undergo percutaneous coronary intervention (PCI). The POPular Genetics trial [24] showed that a CYP2C19 genotype-guided strategy for the selection of oral P2Y12 inhibitors was non-inferior to standard treatment with ticagrelor or prasugrel at 12 months with regard to thrombotic events and a lower rate of bleeding events among 2488 patients with ST-elevation acute myocardial infarction undergoing primary PCI recruited in European countries. Whether these results can be reproduced in East Asian countries remains unclear, but there is a reemerging expectation that similar tactics may benefit East Asian patients
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