Dual Pathway Therapy for Secondary Prevention Following Acute Coronary Syndrome

Abstract

Although dual antiplatelet therapy has served as the standard of care following an acute coronary syndrome (ACS), a significant residual risk of ischemic events and cardiovascular mortality remains. Rather than further targeting the platelet with either a greater number of or more potent therapies, recent emphasis has shifted to treating an alternate pathway, namely thrombin generation, as part of a “dual-pathway” approach to secondary prevention of atherothrombotic events. While early studies combined the administration of antiplatelet agents and vitamin K antagonists and demonstrated a reduction in recurrent MI, there was an unacceptable increase in major bleeding. Combination of antiplatelet agents with novel oral anticoagulants may mitigate this bleeding risk and improve both net clinical outcomes as well as ease of use. The major challenge continues to be the identification of an optimal combination of antiplatelet and anticoagulant agents that strikes a balance between efficacy and bleeding risk. The aims of this article are to review the major clinical trials assessing the safety and efficacy of oral anticoagulants for secondary prevention of atherothrombotic events following ACS and to shed light on future directions in the development of dual-pathway therapy.