Clopidogrel resistance in dual antiplatelet therapy after carotid stenting

Abstract

We read with great interest the article by Ghamraoui et al1Ghamraoui A.K. Ricotta 2nd, J.J. Outcomes and strategy of tailored antiplatelet therapy with ticagrelor in patients undergoing transcarotid artery revascularization.J Vasc Surg. 2021; 73: 132-141Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar reporting about their favorable experience with the use of ticagrelor as part of dual antiplatelet therapy (DAPT) in 67 patients undergoing transcarotid artery revascularization (TCAR). DAPT is the key treatment for patients undergoing carotid stenting, and current therapeutic regimens include a combination of acetyl-salicylic acid and a thienopyridine, the most used of which is clopidogrel.2Ricotta J.J. Aburahma A. Ascher E. Eskandari M. Faries P. Lal B.K. Society for Vascular SurgeryUpdated Society for Vascular Surgery guidelines for management of extracranial carotid disease.J Vasc Surg. 2011; 54: e1-e31Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar However, the pharmacologic “resistance” to the effect of thienopyridines, which can affect about 30% of patients taking that drugs,3Di Dedda U. Ranucci M. Baryshnikova E. Castelvecchio S. Surgical and Clinical Outcome Research GroupThienopyridines resistance and recovery of platelet function after discontinuation of thienopyridines in cardiac surgery patients.Eur J Cardiothorac Surg. 2014; 45: 165-170Crossref PubMed Scopus (27) Google Scholar may increase the risk of periprocedural neurologic events and stent thrombosis. The effect of alternative therapies have been studied mostly on patients with acute coronary syndrome undergoing coronary stenting, for whom ticagrelor has shown greater antiplatelet efficacy compared with clopidogrel.4Barkat M. Hajibandeh S. Hajibandeh S. Torella F. Antoniou G.A. Systematic review and meta-analysis of dual versus single antiplatelet therapy in carotid interventions.Eur J Vasc Endovasc Surg. 2017; 53: 53-67Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar There are currently few studies on patients undergoing carotid stenting, for which the presence of an optimal DAPT aggregation is equally fundamental. In their retrospective experience, Ghamraoui et al1Ghamraoui A.K. Ricotta 2nd, J.J. Outcomes and strategy of tailored antiplatelet therapy with ticagrelor in patients undergoing transcarotid artery revascularization.J Vasc Surg. 2021; 73: 132-141Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar did not observe major bleeding events or cerebrovascular ischemic events or death at 30 days postoperatively with the use of ticagrelor after TCAR. Therefore, the authors concluded that ticagrelor may represent a safe and effective alternative to overcome clopidogrel nonresponsiveness in DAPT regimens for TCAR. Nevertheless, a control group of patients undergoing conventional DAPT regimen with clopidogrel is lacking. Ticagrelor has a well-known low rate of on-treatment platelet reactivity,5Lemesle G. Schurtz G. Bauters C. Hamon M. High on-treatment platelet reactivity with ticagrelor versus prasugrel: a systematic review and meta-analysis.J Thromb Haemost. 2015; 13: 931-942Crossref PubMed Scopus (42) Google Scholar but its routine use in patients in whom clopidogrel may be properly effective may raise some cost issues. We agree with the authors about the need for a tailored approach in patients who should undergo DAPT after carotid stenting, but in our opinion this goal could be accomplished by performing platelet reactivity testing as part of routine care, and switching to ticagrelor in the event of thienopyridine resistance. In our opinion, further studies are needed in the overall population of patients undergoing carotid stenting, to bring evidence either in favor or against the use of ticagrelor as an alternative therapy in clopidogrel nonresponsiveness.