Desaggregant Therapy of Patients With Ischemic Heart Disease: Unsolved Problems

Abstract

At present, choice of antiplatelet therapy in ischemic heart disease (IHD) patients depends on the IHD form, accepted treatment guidelines, contraindications, and cost of drugs. Usually, there is no regular control of the action of antiplatelet drugs. However, in many patients such therapy does not improve the long-term outcome. Increasing dosage of antiaggregants has no positive effect on prognosis. Presently attempts have been made to improve survival by introduction of double or triple drug combinations. Furthermore, although long-term treatment with combination of aspirin and clopidogrel, or both drugs plus one of the new oral anticoagulants (thrombin or a factor inhibitors) has no significant positive effect on total mortality, such therapy significantly increases risk of massive internal and particularly intracranial bleeding. In view of small decreasing effect of such therapy on the rate of reinfarction and stroke, one should search for new approaches. One of such approaches is selection of an antiplatelet drug taking into consideration its effect on the aggregative reactivity of platelets. There are considerable data proving that high residual platelet reactivity (RPR) during antiplatelet therapy is associated with elevated risk of diseases caused by arterial thrombosis. Our research demonstrates that one can overcome high RPR by substituting clopidogrel for aspirin and vice versa or by using combination of these drugs. Indeed, in patients with high RPR during aspirin or clopidogrel monotherapy this combination is associated only with slight increase of number of patients with target level of platelet reactivity. It can be supposed that in this group of patients one of oral anticoagulants (e.g. rivaroxaban) should be used in combination with clopidogrel.