Antitrombocitna terapija u sekundarnoj prevenciji

Abstract

Platelet activation plays a critical role in thrombosis, a major pathophysiologic event responsible for the acute clinical manifestations of atherothrombotic diseases such as acute coronary syndrome, ischemic stroke/transient ischemic attack and peripheral artery disease. Treatment with the combination of aspirin plus P2Y12 antagonist (dual antiplatelet therapy) is an important strategy for preventing ischemic events in patients with acute coronary syndrome, including those undergoing percutaneous coronary intervention. However, patients receiving dual antiplatelet therapy remain at substantial risk of ischemic events because current agents do not interfere with all platelet activation pathways, allowing continued platelet activation via other pathways. The novel P2Y12 inhibitors, prasugrel and ticagrelor, demonstrated superior ischemic outcomes, versus clopidogrel, but event rates remain high, and major bleeding is increased. The use of a combination of proton-pump inhibitors and clopidogrel has recently been questioned due to pharmacological interaction, with possible implications and effects on clinical outcome in patients using this combination. Triple therapy (dual antiplatelet therapy plus a vitamin K antagonist) are recommended as first-line treatment during the initial phase of acute coronary syndrome in patients with atrial fibrillation. Triple therapy is associated with a three- to fourfold increase in major bleeding complications. The management of such patients is challenging owing to the fact that a good level of anticoagulation should be maintained during the acute and long-term phases of the disease.