Oral antiplatelet therapy after acute coronary syndrome and percutaneous coronary intervention: Balancing efficacy and bleeding risk

Abstract

The benefits and risk of bleeding associated with oral antiplatelet agents used for acute coronary syndrome (ACS) or in patients who have undergone percutaneous coronary intervention (PCI) are discussed. Over the past decade, significant advances have been made with the use of oral antiplatelet agents in ACS patients and in those undergoing PCI and stenting. Dual antiplatelet therapy with clopidogrel and aspirin has been considered the gold standard for reducing cardiovascular events in these patients. However, use of clopidogrel has limitations, including variable patient response. These limitations can affect patient outcomes achieved with clopidogrel, leading to concerns regarding its use. Subsequently, more potent oral antiplatelet agents have been developed, including prasugrel and ticagrelor. Prasugrel is an oral thienopyridine with greater potency and less antiplatelet variability than clopidogrel. Ticagrelor, another oral antiplatelet agent that has shown greater platelet inhibition than clopidogrel, is currently under investigation. Although a greater reduction in ischemic events has been observed with dual antiplatelet therapy and the use of newer oral antiplatelet agents, there is also a progressive increase in the risk of major bleeding. Treatment decisions should be based on current practice guidelines, as well as individualized patient risk and benefit analyses. Knowledge of the benefits and bleeding risks associated with oral antiplatelet agents, as well as guideline recommendations, can help health care providers make informed decisions regarding the most appropriate therapy for patients after ACS and PCI.