Minimizing the Risks of Anticoagulants and Platelet Inhibitors

Abstract

Thrombosis is a major contributor to the adverse outcomes associated with atherosclerotic disease. Acute coronary syndromes (ACS) result when intravascular thrombosis occurs at the site of an atherosclerotic plaque rupture. In this setting, the use of anticoagulants and platelet inhibitors is life-saving, but these agents also contribute additional risks for bleeding. The risks and benefits of antithrombotic therapy have been studied in large randomized clinical trials; however, clinicians must extrapolate from aggregate data when making therapeutic decisions for the individual. The validity of such extrapolation becomes less certain when factors encountered in practice differ from those observed in the trial setting. The balance between risks and benefits of antithrombotic therapy in practice may be altered by factors across 3 domains: drug, patient, and provider. Although factors associated with these domains can independently influence outcomes, more commonly, it is the complex interplay of all 3 that ultimately determines the outcome of therapy in a given patient. This article will describe the common risks associated with antithrombotic therapy. In addition, factors that individually or in combination alter these risks will be explored with currently available agents approved for or studied in ACS (Figure 1). Finally, directions for optimizing the future safety of antithrombotic therapy will be discussed. Figure 1. Interdependence of factors associated with risks and benefits of antithrombotic agents. This schematic lists factors grouped as drug-specific, patient-specific, and provider- or system-specific, with arrows to reflect their interdependence. A variety of anticoagulant and platelet inhibitor drugs have been approved for use in ACS patients (Table 1⇓).1 These existing agents have unique pharmacological properties that influence both their comparative efficacy and safety as demonstrated in aggregate trial data and their safety as observed in clinical practice. The most frequently used anticoagulants in contemporary ACS care are unfractionated heparin (UFH) and …